Toward psychiatry as a ‘human’ science of mind. The case of depressive disorders in DSM-5

Abstract

The aim of this paper is to argue that a strictly reductionist approach to psychiatry represents a theoretical and clinical obstacle to a fruitful synthesis between neurobiological and sociocultural aspects of the sciences of mind. We examine the theoretical and practical motivations underlying this approach, by analyzing the case of depressive disorders, as defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), and the related removal of the “bereavement exclusion clause.” We first explore the claim that DSM is atheoretical, observing that, far from being atheoretical, DSM adopts an implicit, biologically inspired view of the mind; we show that such a view leads to a sort of circularity in the definition of depressive disorders, in which psychopharmacology seems to play a key role. We then turn to further problems deriving from this position, analyzing the issue of placebo effects in the treatment of depressive disorders and the philosophical question of normative preconditions for psychopathological diagnosis. Finally, we address the issue of subjectivity, which, together with the related aspect of the subject’s relational context, appears to be crucial to any scientific theorizing about mental disorders, despite DSM’s attempt to exclude it. Our defense of a non-reductionist view of mental disorders, however, does not imply that we endorse any sort of metaphysical dualism, or anti-diagnostic or anti-psychiatric positions. On the contrary, we argue that the adoption of a reductionist position actually undermines the theoretical and clinical accuracy in explaining depressive disorders.

Fostering the Reconstruction of Meaning Among the General Population During the COVID-19 Pandemic

“…Both types of intervention-whether or not directly based on CBT principles-tend to be symptom centered, that is to say, they target discrete, well-defined symptoms, 4 using current diagnostic systems such as the DMS-5 (American Psychiatric Association, 2013) and the ICD-11 (World Health Organization, 2018). 5 There is ample evidence that this approach is rooted in a biomedical model of clinical intervention that has influenced clinical psychology more profoundly than is commonly believed (Henriques, 2002;Deacon, 2013;Frances, 2013;Castiglioni and Laudisa, 2015). Analogously to its treatment of bodily ailments, the biomedical model conceptualizes forms of mental distress as diseases, that is to say, as clusters of interconnected and concurrent symptoms (with diagnostic status) that form a single framework of disease (Hucklenbroich, 2017).…”

“…At the same time, initial psychological assistance should be characterized by active listening, with a view to allowing the client's needs to emerge and be expressed. As argued elsewhere (citation omitted for anonymous peer review, Castiglioni and Laudisa, 2015) in relation to depressive symptoms, throughout the diagnostic process, practitioners should take careful account of the traditional distinction between "endogenous" syndromes, arising in the absence of any apparent external reason, and "reactive" ones, triggered by negative external circumstances.…”

Retiring Categorical Systems and the Biomedical Model of Mental Illness: The Why and the How—A Clinician’s Perspective

“…The DSM system, as a representative example, is a codified system that uses a phenomenological approach based on expert consensus (Gogoi, 2017). This subjective, reductionist, and atheoretical approach (lacking psychological or psychiatric theory) relating to etiology (Pilgrim & Rogers, 2005), takes a biological perspective to the mind, which dismisses advances from neurobiological and sociocultural perspectives, and their contributions, to the science of the mind (Castiglioni & Laudisa, 2015). As a result, the DSM system poses widely acknowledged short-comings to understanding the true nature and sources of psychopathology, including low symptom specificity, prevalent comorbidity, pronounced diagnostic heterogeneity, and poor reliability (Clark et al, 2017;Krueger et al, 2018;Regier et al, 2013).…”

The DSM-ICD diagnostic approach as an essential bridge between the patient and the “big data”

“…15 With the publication of DSM-5 in 2013, the discussion about hyponarrativity was exacerbated, as the manual's new edition was accused (exaggeratedly, in my opinion) that, by removing the bereavement exclusion from the diagnosis of major depression, it virtually abolishes the fundamental distinction between mourning and depression. [16][17][18] Finally, a further criticism is that the DSM polythetic diagnostic criteria differ greatly from the way a clinician actually thinks when making a diagnosis: in reality, diagnosis as a mental process consists not in checking symptoms in a list, but in comparing be-tween the particular case which is being examined and clinical prototypes, that is representative exemplars in the sense of Gestalt, which are invariably formed and acquired mentally and enriched continually with growing experience. 19,20 In this sense, and -I would say-fortunately, the way we diagnose in practice is never so "hyponarrative" as the DSM operationalism would have us believe.…”

“…Nevertheless, the "loss of subjectivity and interpersonal context" of the patient (with which Castiglioni & Laudisa charge DSM) is not only a, so to speak, side-effect of operationalist diagnosis, but bears upon the philosophy evidence-based itself, to the extent that it considers the patient's subjectivity as "a disturbance factor to be eliminated in order to purify scientific analysis of mental disorders". 18…”