Do I have a mental illness? The problem of diagnosis in Mental Health

In order to diagnose a “mental illness” psychiatrists have decided on a paradigm of what is an illness, what to take into account to make a diagnosis, what type of science will be used to make a classification and the usefulness of that diagnosis for the treatment to be carried out.

How is the diagnosis of a “mental illness” made?

There are two Manuals of utmost importance worldwide for making psychiatric diagnoses. In 1938, the World Health Organization created a section on “mental illness” in its Manual of International Classification of Diseases, ICD, in its fifth edition. In 1952, the American Psychiatric Association created the Diagnostic and Statistical Manual of Mental Disorders, the DSM. Both are based on medical and statistical criteria, giving a status to what is considered mental illness from the parameter of physical illness. The one that has predominantly prevailed in the world is the DSM.

“It would not be wrong to say that the DSM is both a cause and a product of the socially dominant thinking about mental health in a given society, the West, at a given time. And its development through different editions is evidence of, as well as an impetus for, the changes produced in this society over the years – just as its international expansion is a sign of the expansion of a particular way of thinking to other cultures and societies. “¹

The problems of the classification of “mental illnesses”.

This type of classification of “mental illness” is currently in crisis, especially since the emergence of the latest manual, DSM V. One of the problems it presents is using the same diagnostic tool to equate subjective suffering with physical illnesses, with the difference of basing its “mental” diagnosis solely on the symptoms expressed by the sufferer or his or her caregivers and acquaintances and their persistence. The only physical tests that a psychiatrist may request are to rule out that there is no biological cause. Despite basing its diagnosis on subjective symptoms, it presents the great problem of the association of certain drugs to certain diseases, as a formula for a drug cure that proves insufficient to address human subjectivity. It is also problematic in presenting itself as verified science. This manual is presented with the status of truth, without justifying the theoretical, philosophical, contextual and historical bases on which it is based. From the transcultural studies carried out, there does not exist and cannot exist universal categories for subjective experience. However, this classification has the pretension of universalization, since it does not support the paradigms that sustain it and present it as a scientific advance.

Does “mental illness” have a biological cause?

In its latest version, the DSM V, it has not been able to include biomarkers to test its diagnoses. This is how the chair of the working group for this latest revision, Dr. David Kupfer, puts it:

“When we began the process of developing this manual 14 years ago, we were all very optimistic that we would have biomarkers and other advances of sufficient magnitude to allow us to use a biological measurement as part of our set of disorder criteria. This has not yet happened… “ ² Despite not having the ability to determine biomarkers to make the diagnosis of ”mental disorders,” treatment is still associated with medicalization and linking them all to biological causes that have not been able to be determined.

However, questioning these manuals can cause a very negative reaction in some people. For many, having obtained a medical-psychiatric diagnosis has brought great relief to their suffering and they have found in the name of their “disorder” an answer to something they could not name before and which gives meaning to their suffering. It is also considered that to question these diagnostic manuals is to deny the existence of a “disorder” that causes suffering. I believe that what is intended by questioning these manuals is quite the opposite, it is to find other ways to explain one’s own suffering that enable another possible treatment, reducing the medicalization of symptoms and proposing other types of community and social responses. It is necessary to bear in mind that in today’s society the biological cause makes it easier to assimilate the difficulties, that the diagnoses are based on the organic gives the sensation of touching wood, of being the closest thing to the truth, for that same reason it is difficult for many people to think that the truth of what happens to them can be in another place, that people are determined by another matter that is not only the organic one.

Another way of understanding “mental illness”

Prior to the publication of the DSM V, the British Psychological Society, through its Division of Clinical Psychology, issued a communiqué stating that a paradigm shift was needed in order to diagnose mental illness, considers that “The major systems that have attracted the attention of the professional community over the past decades have failed in their claim to define specific conditions whose recognition would serve to provide increasingly specific remedies ”³ and has published in 2018 the proposal for an alternative Framework to the predominant diagnostic systems (ICD and DSM), called the Power, Threat and Meaning Framework. In Spain, it is the Spanish Association of Neuropsychiatry (AEN) who has carried out the translation and dissemination of this Framework.

This new Framework aims to provide a much broader perspective on human suffering, taking into consideration that “the patterns that sustain individual and group experiences of suffering are inseparable from their material, environmental, socioeconomic and cultural contexts, and that alternatives to psychiatric diagnosis must place meaning, narrative, agency and subjective experience in a central position. ” ⁴

By not considering the biological cause as the primary factor, it places subjectivity at the center, taking into consideration the framework (given by a historical, cultural, economic, political, social and family context) that the person has had in his or her subjective constitution. What power has been exercised, such as biological and corporalized power; coercive or power through force; legal; economic and material; ideological, etc. How that power has exerted a Threat, taking into consideration the suffering it has generated and its effect. The central role of Meaning, which is determined by social and cultural discourses. And all this results in a Response to the Threat to maintain their emotional, physical, relational and social survival, which can be considered by mainstream psychiatry as abnormal and dissonant symptomatology to be eradicated.

“There are fundamental differences between this model of psychic suffering and the more traditional biopsychosocial model. In the latter, pathology is not assumed. The “biological” aspects are not privileged over the others, but constitute one level of explanation, inseparably connected to the rest. Equally important, although a tripartite model is heuristically appropriate, the three elements are not independent, but shape each other. The individual does not exist, nor can he or she be understood separately from his or her relationships, community, and culture; meaning only emerges when the social, cultural, and biological combine; and biological capacities cannot be separated from the interpersonal and social context. In this context, “meaning” is intrinsic to the expression and experience of all forms of psychic or emotional suffering, giving a unique form to each person’s individual responses. “⁵

I consider it to be a much more respectful framework, open to creating other ways of dealing with human suffering, as well as creating responses based on community care, where everyone can have a place. It breaks with the idea of the rational biological individual totally alien to his or her context, but rather emphasizes that relationship. I leave you here the link, where you can find the summarized version and the more extensive version.

1. Garcías Zabaleta, Oscar. La construcción del DSM: genealogía de un producto sociopolítico, 2018. https://www.redalyc.org/journal/3397/339767305009/html/. ↩︎
2. Kupfer, D. The DSM-5 – an interview with David Kupfer. BMC Med 11, 203 (2013). https://doi.org/10.1186/1741-7015-11-203. Original: “When we started the process of developing this manual 14 years ago, I think we were all very optimistic that there would be biomarkers and other breakthroughs of a magnitude that would allow us to use biological measures as part of our disorder criteria sets. This has not happened yet…” ↩︎
3. Johnstone, L. y Boyle, M. with Cromby, J., Dillon, J., Harper, D., Kinderman, P., Longden, E., Pilgrim, D. y Read, J. (2018). (2018). The Power Threat Meaning Framework: Towards the identification of patterns in emotional distress, unusual experiences and troubled or troubling behaviour, as an alternative to functional psychiatric diagnosis. Leicester: British Psychological Society [trad. cast.: El Marco de Poder, Amenaza y Significado. Hacia la identificación de patrones de sufrimiento emocional, experiencias inusuales y comportamientos problemáticos o perturbadores, como una propuesta alternativa a los diagnósticos psiquiátricos funcionales. Leicester: British Psychological Society, 2020.]. p. 6 ↩︎
4. Idem. p. 9 ↩︎
5. Idem. p. 13 ↩︎