Jason Schnittker - The Diagnostic System: Why the Classification of Psychiatric Disorders Is Necessary, Difficult, and Never Settled

JASON SCHNITTKER

THE DIAGNOSTIC SYSTEM

WHY THE CLASSIFICATION
OF PSYCHIATRIC DISORDERS
IS NECESSARY, DIFFICULT,
AND NEVER SETTLED

Columbia University Press

New York

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E-ISBN 978-0-231-54459-7

Library of Congress Cataloging-in-Publication Data

Names: Schnittker, Jason, author.

Title: The diagnostic system : why the classification of psychiatric disorders is necessary, difficult, and never settled / Jason Schnittker.

Description: New York : Columbia University Press, [2017] | Includes bibliographical references and index.

Identifiers: LCCN 2016056249 (print) | LCCN 2017008748 (ebook) | ISBN 9780231178068 (cloth : alk. paper)

Subjects: LCSH: Mental illnessDiagnosis. | Psychodiagnostics.

Classification: LCC RC469 .S36 2017 (print) | LCC RC469 (ebook) | DDC 616.89/075dc23

LC record available at https://lccn.loc.gov/2016056249

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Cover by Lisa Hamm

T he best place to start a discussion of psychiatric classification is with the people that psychiatric disorders affect directly. Consider two cases, both involving people at the boundary of formal classification. These cases are drawn from the American Psychiatric Associations most recent volume of clinical cases, designed to help mental health professionals learn more about the latest edition of the Diagnostic and Statistical Manual . Olafs daughter lives overseas, and she recently had a baby. Olaf would like to visit his grandchild, but he is severely anxious about flying. His anxiety began three years ago when the plane he was on landed during an ice storm. He has flown since that incident, but on his last complete flight he cried during landing and takeoff. Subsequent to that, when Olaf was scheduled to fly to his daughters wedding, he ultimately refused to board the plane after arriving at the airport. His fear of flying affects more than his family life. It played a role, for instance, in his refusing to accept a promotion that would have involved significant travel. According to Olaf, his anxiety is limited to flying, though with some questioning his psychiatrist discovered that as a child Olaf feared being attacked by a wild animal. His earlier fear of animals was similar in its intensity to his current fear of flying, though it had dissipated because he now lives in a large city where encounters with wild animals are rare. According to the criteria in the Diagnostic and Statistical Manual , Olaf suffers from a specific situational phobia, in this case of flying. His disorder meets all the diagnostic criteria in the manual. It involves intense situational anxiety, it has caused significant distress, and it has caused significant functional impairment. In addition, Olaf also meets the diagnostic criteria for a specific phobia pertaining to animals, but, probably because he is unlikely to encounter wild animals in his current environment, that anxiety plays little obvious role in his life. The DSM permits this additional diagnosis, in part to allow for significant impairment that might be entirely unconscious; for example, Olaf might choose to live in a big city precisely to avoid wild animals. Olaf is not required to acknowledge or state this, however, for the psychiatrist to infer that it might matter.

The second case is Andrew Quinn, whose son recently died. Other features of Andrews situation are relevant to discerning whether this is a case of clinical depression and not just bereavement. In particular, the risk of depression following grief is presumed to be higher for Andrew given his history of depression.

What do these two cases reveal? At one level they reveal something simple: how matters of formal diagnosis hinge on seemingly slight matters. Andrews diagnosis hinges on what we regard as real depression and what we believe is an adequate time to grieve. Making a diagnosis also appears to depend on evidence of a preexisting risk, even if, as in Andrews case, that risk appeared many years ago. With almost exactly the same experiences and symptoms, a person without a history of depression might be regarded as simply bereaved, not depressed, especially this soon after a sons death. Olafs case raises similar issues. In particular, for Olaf there are two sources of anxiety, even though he is concerned about only one. In this case, too, the past is critical. The DSM allows for a diagnosis based on what Olaf experienced in the past. According to the DSM , a disorder might still be present even when it has no apparent symptoms. In this way, the DSM assumes authority over and above what Olaf himself recognizes or appreciates. These two cases also point to the importance of professional judgment in addition to the words and rules of a text. A reliable diagnosis requires that the psychiatrist use the DSM faithfully. Yet a diagnosis also requires that the psychiatrist exert a considerable amount of judgment. In Andrews case, the psychiatrist must decide whether Andrew is really suffering from clinical depression, based on insights that probably stretch beyond the DSM . In particular, the psychiatrist must decide if the particular set of symptoms better describes grief or major depression, even though they are closely related. In Olafs case, the psychiatrist must probe further to learn about Olafs other fears, even if those fears have no obvious relationship with his current anxiety. What, though, compels a psychiatrist to use the DSM faithfully? And when presented with complex patients for whom a diagnosis requires reading between the lines, often based on issues that go well into a patients past, will all psychiatrists make the same determination? Regardless of the details provided in the DSM , psychiatrists are still left wrangling with the meaning of its text when presented with actual patients.