Our previous short article on Depression, contained a few lines about the diagnostic systems employed by classic psychiatry. Some readers raised the question what this DSM is about and some others thought it sounds like a highly technical discussion, best reserved for a workshop. This post is to explain this point further and show why some facts about diagnostic systems or labels such as depression might be of relevance for general public.

DSM stands for Diagnostic and Statistical Manual of Mental Disorders. It is a classificatory system with a universal claim meant for both statistical and clinical research and treatment. It has been published by American Psychiatrists Association since 1952. Even though other comparable manuals, such as ICD, competes with its dominance, its impact globally is undeniable. Currently, the fifth edition of this manual had enlarged the number of mental disorders to an astonishing number of 347 mental disorders. This latest edition’s expanded field has been widely commented. The Scientific French journal La Recherche published a highly critical special issue in September 2012 (La Recherche, 465, June 2012) after the publication of a European survey that had obtained 38% mental disorders among population, which is an ostensibly too high number, and signals the dysfunction of the diagnostic instrument. Specifically, the enlargement of the depressive disorders in the latest edition has been targeted by critics for its lack of coherence. In fact, DSM as a tool has a tremendous social and historical impact. Those diagnostic classes, especially when handled without sufficient skill, stigmatize, rather than appease mental suffering among population. One example is labelling and marking individuals, especially children at an early age. After the immense popularity of ADHD in the crowded classrooms of neoliberal era’s schools in the 1990s, new disorders are “identified” or rather constructed (see among others Child Psychiatry & Human Development, June 2013). Overdiagnosis, introduction of words such as depression or bipolar into everyday language of educators and laymen signal a social trend that can be traced back to the last decade of the last century. That is why even a number of regulatory institutions in Europe declares caution and a need for a better understanding of human suffering beyond the narrow positivist and scientist ambitions of DSM. The most known instance of such an official approach is to be found in a 40-page long study and recommendations by the Belgium’s Superior Health Council in 2019, which advises against the use of categories in DSM (see the document at https://www. health.belgium.be/en/advisory-9360dsm). 

There are two more fundamental problems that should make us hesitate and be cautious about such classificatory systems without denying their limited advantages for modern mental health care. Firstly, the idea that we can establish a number of parameters, group a number of them and qualify this group as a mental disorder may sound somehow scientific in the sense of Linné and botanics, but is this not rather a way to appease the anxiety that a suffering person may induce in the caretaker?  Is this current methodology, with its almost algorithmic automatism, appropriate for the reality of mental suffering whose complexity and multi-factorial etiology defy a mechanistic procedure? Besides, each individual psychiatrist, each regional or cultural location on this planet interpret those parameters differently, as they are not measurable in the same sense that say, the length of a bridge to be repaired or the amount of electricity generated by a power plant. The academically accepted statistical methods such “kappa coefficient” (this method weighs in the agreement between several observers, which is in reality a highly difficult endeavour) is barely sufficient in this respect, but even this method shows very poor results for diagnoses such as depression or schizophrenia.  Consequently, what happens in reality is that institutions are impacted by “trends”, set by a vast array of publications, a good portion of them backed by psycho-pharmaceutical industry. Suddenly “bipolar disorder”, as a diagnosis flares up, first in the US and Europe and later in the rest of the world. Sometimes are these trends preceded by the launch of new pharmaceutical as well, this coincidence is sometimes so glaring that we may speak of a “side effect” of new molecular and chemical laboratory discoveries, as an investigative journalist, Alison Bass, documented in her book, Side Effect (2008).

This last point brings us to the second fundamental problem: the introduction of neurosciences into DSM in the fifth edition poses a number of serious epistemological issues. Mental suffering and changes at molecular level, more specifically, at the level of signal substances called neurotransmitters, are surely correlated; but a correlation at the molecular level, does not explain the aetiology of mental disorder. This latter is operational only at a molar level and is often a historical and social reality (molar means a higher level of organic complexity, like the relation between individual cells and skeleton in a body). It is —to employ Freud’s term— over-determined phenomena. Manipulations at the molecular level can surely impact the tolerance threshold for anxiety as a signal, but such a manipulation operates at the same level as a paracetamol (buluofen to name a commercial brand) in lowering fever temporarily. Fever can be a symptom of many different aetiologies, caused by a virus or an organic disease, but a paracetamol does not affect that aetiology. Besides, an analogy between somatic disease and mental suffering is after all, an analogy, a weak logical connection that requires to be backed by more solid theoretical models. 

However, these shortcomings does not imply that there is some mystical spiritual entity behind human suffering, or that the mental sphere is somehow above and over the somatic and material basis of life. Unfortunately, all forms of spiritualism, including the Jungian analysis and cognitive behavioral therapy thrive in an environment marked by crude analogies and scientism. While the former mystifies the “mind”, the latter idolizes the unthought concept of rationality or spirituality beyond historical and social contexts. 

Psychoanalysis offers a different approach and has refined its theoretical model based on highly sophisticated research by clinicians such as Sigmund Freud, Melanie Klein and Jacques Lacan. Psychotherapy resting upon psychoanalytic research does not oppose or compete with models and ideals of DSM or other botanics. It only states that these methods, if not handled carefully and within their own boundaries, only make things worse! In an institutional context a certain diagnostic language is necessary, but any “fine-tuning” in the sense of adding sub-categories or sub-subcategories to one branch, for instance depression, as it appears in DSM V, can barely help to communicate about the specific features of an individual patient’s suffering. The sober approach of psychoanalysis starts therefore from listening, understanding and research into all meaningful details that are connected to a patient’s suffering and life situation, based on a structural approach to different manifestations of our subjective reality. It is always interested in the deeper structures that determine this or that symptomatic manifestation. It does not base its judgment on the first observation or on symptoms as they show themselves in an acute phase of a mental process. A symptomatic effect, for instance a depressive state, may be caused by a confluence of causes that together makes up a structure, which may have nothing to do with a real melancholia. Instead, it can be a temporary expression of an obsessional neurosis, and is better explained through an understanding of a person’s life situation and concrete history. 

In short, for psychoanalysis (and psychotherapy based on psychoanalysis), a differential diagnosis is a necessary moment, insofar as we do not see mental suffering as a statistical deviation from some arbitrarily or market-oriented construction of normativity, instead what counts is that the person finds its own voice and power to act based on a more profound understanding of the signs and symptoms that at first appear as enigmatic, meaningless and in some cases as extremely tragic for the person, be it an adolescent or an adult. 

1. Bass, Alison. Side Effects. 2008. Algonquin Books of Chapel Hill.
2.  “Sensitivity and Specificity of the Screen for Child Anxiety Related Emotional Disorders (SCARED): A Community-Based Study”, Child Psychiatry & Human Development, June 2013, Vol. 44, Issue 3, p. 391-399.