Five Key Fantasies Embraced by DSM: Page 2 of 2

Five Key Fantasies Embraced by DSM: Page 2 of 2

Fantasy 2: Diagnosis can and should be based on observable behavior

What supports this fantasy that we can limit ourselves to observable behavior? In none of the patients described here can a diagnosis be made without also accounting for the customary, crucial, emotional conflicts in the mind. That one can limit attention to behavior and ignore the complexity of the human mind and call it science, or that one can toss away most of the evidence and call it “evidence-based—these are fantasies. Obviously, the internal conflicts of the patients described here may be difficult to categorize and measure. But what we need is more sophisticated science that accounts for the mind, not an unscientific attempt to dismiss much of our best data.

Perhaps in addition to facilitating a circumscribed form of science, “behavior only” fantasy helps us defend against the messiness and discomfort of many of our feelings and fantasies, as we would expect from working with our patients.

Beyond this foundational fantasy underlying our current DSM—that we can manage with only observable behavior—let’s consider a number of what we might call corollary fantasies.

Fantasy 3: DSM categories are meaningfully separate

Much research has established that many DSM categories are indeed discrete and useful, but again, this should not lead the student or reader to unquestioningly accept that this is always the case. As noted, many patients in the real world do not read the textbooks and confine themselves to our given categories. The fact that anxiety and depressive symptoms occur simultaneously has recently become a widely recognized limitation of DSM. The concept of “comorbidity,” the idea of having diagnoses from 2 categories at once, has merit on the one hand, but on the other is an attempt to bolster an inadequate system. By analogy to color, is the pattern better understood as blue and yellow, or as green, stripes, a check, or a complex multicolored plaid?

Beyond its limited utility, what propels the fantasy of separateness? To me, it always seems like another compulsive symptom: Don’t let the peas touch the potatoes! Do we professionals tend to be compulsive? Of course!

Fantasy 4: A DSM category represents a homogeneous entity

Mr D and Mr E—both of whom received a diagnosis of DSM unipolar depression—are often assumed to have the same psychiatric disorder. Mr D, who had narcissistic features, became depressed in his 40s, because his professional accomplishments had fallen short of his grand expectations and his relationships had proved unrewarding. Mr E, after spending 2 years valiantly caring for his dying parents, became depressed after they died. His parents’ illnesses had revived his well-earned, usually suppressed, childhood wishes to murder them. No longer serving penance of endlessly caring for them, he could not tolerate his now conscious joy and relief at their deaths, and he became deeply, guiltily depressed.

To what extent is it therapeutically useful to consider that these men had the same psychiatric disorder? Does using the vague DSM term “affective disorder” offer an apparent explanation that takes attention away from significant affects, such as anger, anxiety, guilt, and sadness?

One might ask similar questions in relation to Ms F, Ms G, and Ms H, all of whom have anxiety and, not meeting criteria for any of the DSM discrete anxiety diagnoses, would be said to have anxiety disorder NOS (not otherwise specified). Ms F had anxiety with separations and with the possibility of more independence from her mother; Ms G had become anxious over peripartum struggles with intolerable anger directed toward her baby; and Ms H, who had been sexually abused as a child, became anxious whenever a man expressed interest in her.

In all of these cases, DSM treats different entities as the same, offering a rather nonspecific diagnosis and ignoring the possibility of a more specific (and potentially useful) dynamic diagnosis. In these examples, DSM, if taken seriously, inhibits useful thought about treatment instead of promoting it.

What supports the fantasy that these different patients should be given the same diagnosis? Again, I think this fantasy helps decrease anxiety about the complexity of human feelings and conflicts. It offers a relieving feeling of simplicity.

Fantasy 5: A diagnosis can be made at the beginning of the treatment

When DSM-III came out in the 1980s, I recall a senior psychiatrist who found it a source of great amusement: “They want the diagnosis at the beginning!” He would struggle to say this through his laughter, adding that one only really understood the diagnosis—the underlying pathological structures and fantasies—late in the treatment. Obviously, in many situations, it is essential to make a provisional diagnosis promptly, but it is worth remembering how limited this initial impression can be and how much situations can change and evolve. Anxiety symptoms may arise in depressed patients as their depression lifts. Anxiety can cover sadness and depression. This fantasy is encouraged by our wishes for professional omniscience, in addition to being supported by many of the same reasons as the fantasies that precede it.

Conclusion: My DSM fantasy

I envision the day when psychiatry and psychology re-embrace the mind, along with the brain and behavior. Then, diagnosis will routinely and comprehensively include descriptive, developmental, and dynamic mental and behavioral features of patients. Neurosis, or some way of conceptualizing mental conflicts, will return to DSM. The absence of such a concept will no longer result in the unfortunate in-attention to patients’ dynamics that the recent DSMs tend to foster. Descriptive and dynamic psychiatry will ride off together into the sun-set, even as clichs vanish from my writing.


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