René J. Muller, PhD

[[{"type":"media","view_mode":"media_crop","fid":"23738","attributes":{"alt":"mall shooting","class":"media-image media-image-right","id":"media_crop_1372615538816","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"1955","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right; margin: 5px;","title":"","typeof":"foaf:Image"}}]]On Saturday, January 25, Darion Marcus Aguilar, 19, entered the Zumiez skate shop at the Columbia Mall in Maryland and shot Brianna Benlolo, 21, once, and Tyler Johnson, 25, multiple times, then put the 3-foot-long shotgun he had used to kill them in his mouth, pulled the trigger, and joined them in death.

Once again, as with so many other multiple murders, no motive was immediately apparent. And once again, the words “senseless” and “meaningless” were used to fill the vacuum of non-comprehension. The first clues came from the police who read Aguilar’s journal, found in his home in College Park soon after the murders.

In periodic entries he made to this journal during the previous year, Aguilar acknowledged having a “general hatred toward others.” He wrote about killing people, said he was “ready to die” and stated that an unspecified plan had been “set.” He spoke only generally about his murderous intent and said nothing about a venue for the projected event.

Aguilar acknowledged in his private text that he was mentally ill and regretted that he had not reached out for help. He had insight into his deteriorating condition, as he felt himself slipping away from rationality and health. And he had compassion for his family, apologizing ahead of time for the destructive action he was about to take.

For Darion Aguilar, to be “ready to die” at the age of 19 meant breaking his tie with a world he had never been sufficiently anchored in. To develop an adequate sense of self-a viable identity-a person has to master certain challenges presented by his environment, which, in the early years, involve mostly the family. Later, school, work, friends, love interests and a looming adulthood offer more complex challenges.

Aguilar’s mother separated from his father in 1999, when the boy was about 4 years old. We have few details about this family, but the darkness that pervades Aguilar’s journal suggests there was never much light in the boy’s life. At age 19, hope was nowhere on his horizon.

At some point, Aguilar’s unmet expectations and needs drove him to an anger and hatred

that were projected onto everyone and everything around him. He kept these feelings hidden from his family and friends, who saw him as mild-tempered and introverted. As his anxiety, anger and depression-the main components of his mental illness-mounted, his relation to the world and everyone in it was pathologically transformed. He could not, or would not, sustain the diminishing stake he had in this world. Isolated, despairing, he felt that his life was not worth living, and decided to end it.

Not satisfied with just killing himself, Aguilar took with him two surrogates whose death would be part of his revenge against the world. By all accounts, Brianna Binlolo, a beautiful woman, with a two-year-old son, and Tyler Jackson, who appeared to be doing well in his struggle against drug addiction and was helping others deal with their addiction, had done him no harm. But by Aguilar’s reckoning, they too had to be destroyed, and exit the world alongside him.

We can think of Aguilar as acting with a pathologically transformed rationality that made sense only to him. His life was, as the psychiatrist J. H. van den Berg put it, the “different existence” of someone who is mentally ill, though there is no evidence that he was ever psychotic. Misusing his freedom, he methodically accomplished his pathological goal.

Considering the nature of Aguilar’s illness, there is good reason to believe that his tragic end could have been prevented if the severely defensive stance he adopted toward the world had been challenged by psychotherapy, and medication had been used to manage his symptoms.

Dr Muller is currently working on a guide for diagnosing mental illness that is based on the psychobiology of Adolf Meyer and the Johns Hopkins perspectives of psychiatry.

Articles

In periodic entries in his journal, the Columbia Mall shooter acknowledged having a “general hatred toward others.” He had insight into his deteriorating condition, as he felt himself slipping away from rationality and health. 

The Columbia Mall Shooting

Elyn R. Saks is a lawyer and a professor at the University of Southern California Gould School of Law. In a book aptly titled 

 she tells how she managed to achieve this goal in spite of a chronic mental illness that was diagnosed, at different times, as paranoid schizophrenia and schizoaffective disorder, depressive type.

Elyn grew up in Miami, Florida, graduated from Vanderbilt, received a B Phil from Oxford, and a law degree from Yale-all with the highest distinction. This in spite of her struggle with a hydra-headed psychosis that came and went but never went away, and a “center” that disintegrated again and again, after being temporarily restored with the help of therapy, friendship, work, and psychotropic medication.

The first indications that Elyn might be heading for a difficult psychological life came while she was an undergraduate at Vanderbilt.

Her anxiety was constant, although less while doing academic work, from which she drew most of her identity.

Away from home, faced with new challenges and new expectations, Elyn began to “unravel.” She describes herself as “frantic during the day, sleepless during the night,”

 and she found it hard to concentrate and to think clearly. This daughter of fastidious professional parents let her hygiene slip, even as she realized that her body “stank.”

“My best guess,” she writes of that time, “is that my illness was beginning to poke through the shell (for lack of a better word) that helped me, indeed helps all of us, maintain a separation between what is real and what is not. For the next few years, that’s where things would precariously balance-me unwittingly trying to keep the shell strong, and my illness trying equally hard to break through.”

 In this psychic tug of war, substance abuse was not a contributing factor. Unlike many patients who begin to show signs of a major mental illness at her age, Elyn did not abuse drugs or alcohol.

In spite of a psyche that was increasingly blurring the boundaries between fantasy and reality, Elyn graduated from Vanderbilt with a perfect academic record, was named class valedictorian and won a Marshall scholarship to study ancient philosophy at Oxford-where her life really began to fall apart. There were trips to the emergency room, stays in psychiatric hospitals, psychiatrists and psychoanalysts, and psychotropic medications.

At Oxford, Elyn continued to excel academically even as reality became a tougher slog, and she retreated further into her fantasy world. She did not feel herself to be real, live, and continuous as R. D. Laing characterized the grounding of the ontologically secure person in 

 Nor did she experience others as real, live, and continuous. It was as if she lived behind a wall of glass-Silvia Plath’s bell jar comes to mind-cutting her off from what was going on around her. Elyn became frustrated and angry in her isolation and turned that anger against others, seeing ulterior motives where there were none. In fact, she had a coterie of loyal friends, teachers, and colleagues.

In her dreams, Elyn killed these friends, teachers, and colleagues because she was able to trick herself into believing that they wanted to kill her. This “killing” was how she feigned control when in fact she had ceded control to her illness, or her illness had taken it from her (most likely, it worked both ways). Elyn was self-deceived, depressed, paranoid, and psychotic much of the time:

Psychosis is like an insidious infection that nevertheless leaves some of your faculties intact; in a psychiatric hospital, for example, even the most debilitated schizophrenic patients show up on time for meals, and they evacuate the ward when the fire alarm goes off. So it was for me. Completely delusional, I still understood essential aspects of how the world worked. For example, I was getting my schoolwork done, and I vaguely understood the rule that in a social setting, even with the people I most trusted, I could not ramble on about my psychotic thoughts. To talk about killing children, burning whole worlds, or being able to destroy cities with my mind was not part of polite conversation. 

At times, though, I was so psychotic that I could barely contain myself. The delusions expanded into full-blown hallucinations, in which I could clearly hear people whispering. I could hear my name being called when no one was physically around-in a corner of the library, or late at night, in my bedroom where I slept alone.

While at Oxford, Elyn became the patient of a Kleinian psychoanalyst-Mrs Jones-with whom she formed a strong therapeutic alliance, and whom Elyn credits with being the “glue” that held her together, if precariously: “I was falling apart, flying apart, exploding-and she gathered my pieces and held them for me.”

 After 3 years of intense psychoanalytic work, and finishing her B Phil, again with high distinction, Elyn considered staying in England to continue therapy. But Mrs Jones encouraged her to return home. As expected with someone of Elyn’s psychic fragility, the prospect of losing this alliance induced great anxiety and led to a regression:

I go to my session. I threaten Mrs Jones with a knife. I am very psychotic and out of control. Mrs Jones is kind and gentle. She asks me for the knife and I give it to her. I start screaming. I throw myself against the wall. Mrs Jones and her husband restrain me. The ambulance arrives and takes me to the hospital. I become out of control again and am subdued. I am crying and sobbing that I will be leaving Mrs Jones . . . . Mrs. Jones had been the glue that held me together. With that glue soon to be gone, would I not shatter into a thousand pieces? The anxiety was overwhelming, and our sessions became more intense and hallucinatory.

You can’t leave. I won’t let you. Plupenitenary issues must be addressed. That’s a dress. Come home with me, please?

 I think, you see, that you make yourself confused because you want to avoid the pain of separation. It’s upsetting to think I have a life of my own, apart from you. You are trying to live inside me.

Elyn has fused with Mrs Jones by obliterating the person-to-person boundaries that nonpsychotic persons observe. She has crossed a line in her attempt to 

 the person who has provided the “glue” that allowed her to have a fledgling, brittle center of self. Note the neologism plupenitenary and the clang association addressed/dress, which are indications of formal thought disorder-an upshot of the psychotic mind’s need to create different words and different links between words.

While psychotic, Elyn was mostly lost to the world of reality, and had no insight. During a stable interval, she looked back on what that was like for her: “With psychosis, the wall that separates fantasy from reality dissolves; inside my head, the fantasies were real, and everything was actually happening. The images I saw, the actions I took, were all real, and it made me frantic.”

After graduation, Elyn left Oxford and Mrs Jones, returned to Miami and stayed with her parents until fall when she moved to New Haven to begin law school at Yale-where she continued her pattern of academic excellence and periodic ontic collapse. Her psychotic episodes became more severe and bizarre, requiring physical restraint and, eventually, her first antipsychotic medication, which she strenuously resisted verbally and physically. During the next few years, this drug (unnamed in the book), was replaced in turn by perphenazine, thiothixene, olanzapine, and clozapine, as eventual inefficacy and adverse effects demanded a change.

No drug completely erased Elyn’s psychotic symptoms, but each, for a time, lessened these symptoms and their impact, allowing her to finish law school, though not without taking a year off to deal with her illness. After Yale and several short-term jobs, Elyn was hired to teach at the University of Southern California Gould School of Law, where she was promoted to professor and given tenure. She married her longtime boyfriend, Will, who was as dedicated to serving her needs as any man possibly could be.

As Elyn lived with and against her illness, she became increasingly analytical and insightful as we can see in this cri de coeur: “I needed to understand what lay behind my terrible thoughts and feelings and how my psychosis served to protect me.”

 We might ask, How did she come to have these “terrible thoughts and feelings” in the first place? Whom or what did she need to be protected 

Elyn gives little space in her book to her parents, but what she does say about them seems probative. Both parents were emotionally distant from their daughter: “[T]here was a wall of appropriateness between us at all times; in fact, we’d spent years carefully constructing it, I on one side with my particular set of tools, they on theirs, with the tools they’d chosen.”

Had Elyn’s mother been “good enough,” in the Winnicott sense? And her father? At all stages of Elyn’s life, they seem to have been such vague presences, as if they were there, but not there for her. A family therapist noted that the parents had “made light of [her] illness and didn’t seem willing to accept its seriousness.”

 Elyn admits to being complicit in this cover-up: “I always did everything I could to 

 its seriousness: I cracked jokes, and laughed, and was gratified when they did the same. It was our way of handling it. It was our habit-and every family has its habits. The levity and irreverence made it possible for us to be together without everyone falling completely apart.”

 Laing might have said that Elyn and her parents had denied their being to save their being-

It eventually occurred to Elyn that a double trickery had ruled her life:

The illness-the entity-is always just off to the side, just barely out of my sight. But I know it’s there. And it tries to trick me into believing this isn’t the real Will, and this isn’t the real Steve [Elyn is describing Capgras syndrome, a delusion where she came to believe that her husband and closest friend were imposters], that reality isn’t reality, that I can kill thousands of people with my thoughts, or that I’m profoundly evil and unworthy. 

At the same time, I’m trying to trick the people around me. I’m OK. I’m functional, I’m fine. And maybe, sometimes, this determined effort to trick them tricks the illness itself. It’s like one big con. Steve says he’s never seen anyone who fights as I do. I don’t consider myself a fighter (and I certainly don’t come across as ferocious). But if he’s right, then perhaps in my childhood, and in this push-pull with my parents, one can see not only the beginnings of my illness, but the seeds of my health and strength as well. If I’m a fighter, perhaps it’s because that’s who they taught me to be

Without directly saying that her parents had a role in the development of her psychosis, Elyn, perhaps influenced by Laing and Bateson,

 considers that possibility. The “push-pull” with her parents sounds like the kind of mixed discourse, comprised of 2 incompatible and emotionally conflicting signals that Bateson characterized as a double bind. Bateson believed that such a conflict, 

, can, through a “twisting” of the psyche, lead the child to fragment reality and create the kind of psychotic thought, behavior, and discourse that Elyn lapsed into.

One can imagine Elyn as a child being in what Laing calls a state of ontological insecurity-profound anxiety about who she was and how she was to live-putting on a false self-“I’m fine, I’m strong; I don’t need you”-and the parents, caught up in their own self-absorption and blindness, wanting to believe her pose, responding with the same emotional coldness that they appear to have shown throughout Elyn’s life. This nonresponse to Elyn’s needs may have deprived her of the nurture necessary to trust the world sufficiently to take on the challenges of each new developmental milestone, leaving her mind and brain primed for developing a chronic mental illness.

Elyn knew that she would most likely never be entirely free of her illness. However, during a hospitalization at the Yale Psychiatric Institute, when she was initially floridly psychotic (“People are controlling me, putting thoughts into my head”

), and on a high dose of antipsychotic medication, she began to see that she could do something significant to help herself. After weeks of miserable and contentious confinement, her psychosis began to lift, and Elyn had an epiphany:

And then something threw a switch in my head, and I got it. I got it. The only barrier between me and the door out was me. I simply had to stop it. Stop voicing the hallucinations and delusions, even when they were there. Stop babbling incoherently, even if those were the only words that came to my lips; no, no, it was better to be quiet. Stop resisting; just behave. 

Being in a psychiatric hospital is nonsense, I thought. I am a law student, not a mental patient. I want my life back, damn it! And if I have to bite my tongue until it bleeds, I’m going to get it back.

By being “quiet” Elyn meant not just putting on an act but making an effort to at least mute her psychotic constructions, until she could face the world more realistically without them: “Maybe I couldn’t keep the thoughts from coming into my head, but I could organize them, and keep them from getting out. 

 For the first time, it seems, Elyn was asserting herself as an active agent against the illness itself, realizing that she had some complicity in the condition she found herself in, and some capacity to overcome that condition as well.

Near the end of the book, Elyn gives credit to Dr Freed, a psychoanalyst, who, she says, “helps me to understand how I sometimes use my psychotic thoughts to avoid the ordinary bad feelings that everyone experiences-sadness, rage, garden-variety disappointment . . . he tries to understand my psychotic thoughts as unconsciously motivated and meaningful (which of course they are).”

As she brings her story to an end, Elyn is still taking clozapine and is told by her psychopharmacologist that she will most likely have to take some antipsychotic medication for the rest of her life. She credits both psychoanalysis and psychopharmacology for the progress she has made. “While medication had kept me alive,” she acknowledges, “it had been psychoanalysis that had helped me find a life worth living.”

 For someone so long and so tightly in the grip of a psychotically transformed world as Elyn has been, the challenge of breaking that defensive structure is probably in some ways akin to breaking an addiction to a chemical substance.

Elyn’s descriptions of her psychotic (and normal) experiences are taken here to be primary data, in the way that numbers, and the statistical elaboration of these numbers, are considered data in the empirical approach to studying psychopathology. Hermeneutic analysis of what Elyn tells us about her fall into psychosis and her efforts to have a career and a life-her 

 of the phenotypes of the heterogeneous illness we call schizophrenia. Her narrative draws us into the interior world of the psychotic person, territory that few clinicians attempt to access or assess.

The Center Cannot Hold: My Journey Through Madness

. New York: Hyperion;  2007.
2. Laing RD. 

The Divided Self: An Existential Study in Sanity and Madness

. Baltimore: Penguin  Books; 1965.
3. Bateson G, Jackson DD, Haley J, Weakland J. Toward  a theory of schizophrenia. 

In spite of a chronic mental illness (schizophrenia)and a psyche that increasingly blurred the boundaries between fantasy and reality, this lawyer and professor graduated from Vanderbilt with a perfect academic record.

Eliciting the Phenomenon of Schizophrenia From an Autobiographical Narrative

Dr Muller's essay includes a quote from-and a challenge to-Michael B. First, MD and Robert L. Spitzer, MD. A response by Drs First and Spitzer is also posted on this website and 

What is transparent to one person may be opaque to another. It is clear to me that before symptoms can be used to make a valid psychiatric diagnosis the 

 of these symptoms must be taken into account. Many clinicians do not see it that way. Neither did the DSM-III and its subsequent editions.

The third edition of the 

Diagnostic and Statistical Manual of Mental Disorders

, which came out in 1980, decreed that diagnosis should be made without regard to the meaning of symptoms that constitute the behavioral criteria for a mental disorder. The rationale for this omission goes back at least to Auguste Comte (1798-1857), the French philosopher and mathematician whose work led to logical positivism, the belief that the qualitative, subjective contents of the mind were beyond the comprehension of philosophy and science, and thus should be ignored in favor of quantitative, “objective” data derived from subjective experience.

, the German existential psychiatrist Karl Jaspers, MD, distinguished 2 ways of knowing: 

. The German philosopher of history Wilhelm Dilthey (1833-1911) had already used these terms to name the different kinds of knowledge allowed by the human sciences (qualitative psychology, history, and literary criticism: 

), and the natural sciences (quantitative psychology, chemistry, and physics: 

). Jaspers’s use of this distinction in psychiatry helps us to see why 

, can set the clinician on the path to a correct, if incomplete diagnosis.

With 

, Jaspers named the intuitive, psychological knowledge that one person can acquire about another person, or some aspect of human behavior, what he called the “psychology of meaningful phenomena.”

Psychic events ‘emerge’ out of each other in a way which we understand. Attacked people become angry and spring to the defence[sic], cheated persons grow suspicious . . . Thus we understand psychic reactions to experience, we understand the development of passion, the growth of an error, the content of delusion and dream; we understand the effects of suggestion, an abnormal personality in its own context or the inner necessities of someone’s life.

 comes down to knowing a phenomenon subjectively by intuiting its essence. In contrast, 

 designates a more objective way of knowing, based on empirical study, which attempts to disclose the 

 of a phenomenon. In psychiatry, this is the biological mechanism through which a symptom comes into being. To understand the meaning of a symptom is to know what part an abnormal thought, emotion, or behavior plays in a patient’s life-story narrative. To explain that symptom would be to know how the thought, emotion, or act originates through a dialectical interplay of the patient’s mind and brain with the world he lives in and through. 

Jaspers was not opposed to incorporating biology into the overall understanding of the patient. He was, in fact, a “biological existentialist,” as Nassir Ghaemi, MD

 has pointed out. Jaspers’s epistemological distinction between 

 helps us to realize that we can know the meaning of a symptom without knowing its biological cause. This insight should encourage clinicians not to eschew the understanding (meaning) of psychiatric symptoms just because biological explanations elude them. It may eventually have to be conceded that some mental disorders cannot be 

 in the Jasperian sense, and that the fullest 

 that can be had is “explanation” enough.

became the standard for diagnosing psychiatric disorders during a time when neuroscience, the science of the brain, was producing data that were expected to 

psychiatric symptoms (in the Jasperian sense). But the biological “explanations” produced so far do not point to a unique pathophysiology for any mental disorder. Michael B. First, MD, professor of psychiatry at Columbia, who worked with Robert L. Spitzer, MD, on the DSM-III from the beginning and is still involved in its revision recently acknowledged: “[A]lthough the text of the DSM-5 will be enriched by the fruits of neurobiological research from the past 20 years, neurobiology and genetics will not inform the development of diagnostic criteria in DSM-5

[promised now for 2013]. Diagnostic criteria will therefore continue to be based on clinical findings.”



In effect, the DSM-III allowed that, in making a diagnosis, a clinician didn’t have to either understand 

 explain the symptoms that comprise a mental disorder. It was tacitly assumed that because there was a one-to-one correlation between abnormal behavior and some vaguely specified brain abnormality 

behavior alone was sufficient to define and diagnose the disorder

 (some prestidigitation entered in here). The implication was that if you can 

 a mental illness, however inadequately, you do not need to 

 it. The meaning of psychiatric symptoms was relegated to the slag heap. As written now, the DSM harbors an insidious irony: it is possible for someone to “make criteria” for a mental disorder and not actually 

 that disorder! (For some mental disorders, the DSM-III

do ask for evidence, if minimal, from the patient’s “internal world,” which is phenomenology in the philosophical sense of that word. Eliciting feelings of “worthlessness” or “excessive guilt” in the diagnosis of Major Depressive Episode is not, strictly speaking, basing the diagnosis on behavior alone.)

In my book 

I argued that taking an agnostic position on the meaning of symptoms, where clinicians and patients ignore the provenance of pathological behavior, was an invitation to misdiagnosis. I have found this to be true in patients with all mental disorders and particularly in those who have “mood swings,” which can vary from normal to severely pathological. At the extreme end of this spectrum of cyclic mood change is the illness known as bipolar I disorder, which Kay Redfield Jamison has described vividly and poignantly in 

 Jamison’s classic symptoms of full-blown mania, alternating with severe, sometimes suicidal depression made her diagnosis straightforward, though her symptomatic illness went undiagnosed for many years.

By providing a meaningful description of her long struggle with manic depression Jamison made it clear that she thoroughly 

 her illness. She knows what life events contribute to her stability, as well as what undermines that stability. But, beyond some biological generalities, she cannot 

 how she came to be bipolar or what constitutes the pathophysiology of her illness. Neither can anyone else.

Because the pathophysiology of bipolar 1 disorder is not known, and because the DSM diagnostic phenomenology (here phenomenology simply means symptoms) is vague, except in the most prototypical cases like Kay Jamison’s, patients with mood swings, which may be due to a variety of causes and thus have a variety of meanings, are often misdiagnosed with some form of bipolar disorder.


One of these patients is a friend of mine. In 

, I told “Adam’s” story, starting with his first episode. At a lacrosse practice during his freshman year in college, Adam got into an altercation with the coach and was asked to leave the field. That night the team captain came to his dorm room to convey the displeasure of the coach and some team members over what had happened. Adam felt he was in significant danger, and panicked. He called his sister, who agreed to drive to the campus and bring him home.

Before the incident with the coach, Adam had been failing most of his courses and was using multiple drugs in large amounts: LSD, alcohol, and several different kinds of pills. At home, his parents were flabbergasted by their son’s behavior. Convinced that the coach and the team were planning to physically retaliate against him, Adam was paranoid and out of control. The next day, he was voluntarily admitted to a psychiatric hospital, the first of many hospitalizations. That was in 1985, and the beginning of a tortuous association with the mental health profession that continues to this day.

Adam’s doctors got him wrong from the start. Their first mistake was to underestimate the role that drugs and alcohol played in his behavior. Then they tried to fit that behavior, 

which they never attempted to determine the meaning of

, to one DSM diagnosis or another. At different times, the diagnosis was bipolar 1 disorder, schizophrenia, and schizoaffective disorder, in spite of the DSM-III prohibition against making these diagnoses in someone who had used illicit drugs and alcohol heavily for several years, including at the time of his first episode, and sporadically for years after that. Ultimately, it became clear (to me, anyway) that Adam’s paranoid behavior was rooted in fears that he did not recognize, and thus could not handle, as well as his continued drug use.

Though I was never Adam’s therapist, I did try to act as a therapeutic presence for him by challenging his self-deception and encouraging his authenticity. Adam’s life-story narrative is the key, I believe, to 

 why he thought, felt, and behaved as he did. The son of an alcoholic father, and a mother who drank heavily and had histrionic features Adam grew up with considerable anxiety about his ability to play the role expected of him by his upper-middle-class, WASP family. Eventually, he came to realize that the paranoia that was such a prominent part of his problem (as well as the diagnoses wrongly given to him) was driven by this anxiety. Over time, Adam was able to let go of the paranoid defenses that he had used to avoid what was going on in his life.

To Jaspers, this narrative analysis would have constituted an 

 of Adam’s illness, its existential and psychodynamic meaning. But Adam’s doctors were convinced that he had some kind of “chemical imbalance,” and diagnosed him at different times with various Axis 1 disorders. Clearly, these diagnoses were bogus. The fact is that psychiatry is not 

, or cause, for Adam’s pathology. I believe I know what Adolph Meyer, MD, had in mind when he wrote, “We understand this case; we don’t need any diagnosis.”



I chose to retell Adam’s story here because it reveals how the DSM-III

and its later editions are a virtual invitation to get a psychiatric diagnosis wrong. Adam’s doctors 

 nothing and explained nothing about their patient’s troubled life. Instead, they tried to match his symptoms to the exclusively behavioral criteria of the DSM, effectively “stretching” his behavior to fit one diagnosis, then another, even as they acknowledged to him that none of these diagnoses was a good fit. As far as I can see, the only valid diagnoses Adam was given were for substance dependence and depression.

Adam’s psychiatrists had excellent credentials and he was treated at one of the country’s foremost mental hospitals. To me, the fact that such highly regarded doctors, working at a respected institution could miss the mark so widely, and then persist in this mistake for nearly two and a half decades says that the current paradigm of psychiatry, defined as it is by the DSM’s agnostic symptoms and the alleged “chemical imbalance” is deeply flawed.

When the DSM-III was created, the thought was that over time they would do a lot more research and these made-up definitions would become filled in by data and ultimately these categories would become real diseases. Well, it’s turned out, 27 years after DSM-III, that things are much more complicated than anticipated. Not a single phenotypic marker or gene has been identified that’s diagnostically useful, which is of course very disappointing. There’s almost no treatment specificity. There’s clearly a serious problem with the underlying validity of the DSM if these things don’t correspond very well to nature.

I would like to put these questions to Drs Spitzer and First: How could you have expected that the empirical diagnostic categories you carved out of the whole cloth of psychopathological behavior to correspond to nature, to be real, when you deliberately took reality, the meaning implied by Jaspers’s 

, out of these categories up front? How can a valid diagnosis and effective treatment be based on an idea that flies in the face of reality? Did you expect this to turn out well?

To the makers of the DSM-III, subjectivity became a dirty word because it evoked the specter of (mostly Freudian) psychoanalysis, whose limitations the new diagnostic classification system was created to overcome. For me, taking into account a patient’s subjective experience, which may be better thought of as his 

, has nothing to do with the kind of psychoanalysis that the DSM-III rejected. After years of studying European existential psychiatry, a tradition that is not well known in North America, I have come to see that the best way to diagnose and challenge psychopathology is to begin, a la Jaspers, by 

understanding what the patient is thinking, feeling, and doing

.

I believe it is possible to be at least somewhat objective about another person’s subjectivity, or personal experience, though I’m not sure that “objective” is the best word to convey what I mean here, in part because that word can have different meanings. My ultimate goal is to get the patient right, with my subjectivity intuiting his subjectivity.



Psychiatry needs a new diagnostic paradigm


In a future edition, the DSM, or whatever improved classification system eventually replaces this wrongheaded and largely invalid taxonomy, needs to take into account the patient’s subjectivity, and the meaning, or context, of his symptoms-not by simply tacking on another axis, but by 

making the articulation of this subjective experience the principle objective of the diagnostic process

. Until then, psychiatry will continue to get it wrong, and there will be more disasters like the one inflicted on Adam.

Achieving a valid diagnostic paradigm will require acknowledging that psychiatry is often less “medical” than the current DSM implies, and that with some patients, psychiatry needs to be more art than science. Scientists who are trying to explain mental illness biologically continue to speak as if satisfying explanations for these illnesses will be forthcoming, but the results of their efforts so far are not reassuring on that point.

 A brain scan showing that a symptomatic patient has more or less blood flow in a specific brain area tells us little about the biological essence of the illness, or how to treat the illness.
 
Until we know enough to offer a valid 

 for why people develop mental illness, we need to focus on 

 how and why our patients’ lives have gone wrong. This is the only authentic and valid starting point for our therapeutic intervention.

. Trans. J Hoenig and MW Hamilton. Foreword PR McHugh. The Johns Hopkins University Press; 1986[1913]:202-203.


Ghaemi SN. The psychiatric humanism of Karl Jaspers. 

. 2008;3. Available at http://www.bu.edu/paideia/existenz/volumes/Vol.3-2Ghaemi.html. Accessed July 15, 2010.


First MB. Changes in psychiatric diagnosis. 

Doing Psychiatry Wrong: A Critical and Prescriptive Look at a Faltering Profession

. New York: The Analytic Press/Taylor & Francis Group; 2007:33-43.


An Unquiet Mind: A Memoir of Moods and Madness.

Modern Clinical Psychology: Principles of Intervention in the Clinic and Community

Klerman GL, Vaillant GE, Spitzer RL, Michels R. A debate on DSM-III. 

 Fox R. DSM-V boasts more research, disorder details. 

American Psychiatric News. January 2008, p 14.


What is transparent to one person may be opaque to another. It is clear to me that before symptoms can be used to make a valid psychiatric diagnosis the meaning and context of these symptoms must be taken into account. Many clinicians do not see it that way. Neither did the DSM-III and its subsequent editions.

Psychiatric Symptoms Can Be Understood Even When These Symptoms Cannot Be Explained

Anger is an emotion that is familiar to everyone. An episode of anger may dissipate quickly and harmlessly or evolve into a murderous rage. Between the benign and malignant end points in this spectrum, a seething, chronic anger may come to dominate a person’s thinking, feeling, and behavior.

Despite the universality of anger, psychiatry has not addressed this emotion as a phenomenon in its own right. Anger is mentioned in the 

 only as a symptom in personality disorders and drug withdrawal syndromes. There is no listing for anger in either the 

’s index or the glossary of technical terms.

The instrumental, differentiated world of normal mood

, the French existential philosopher Jean-Paul Sartre parsed the meaning and structure of the common emotions, including anger.

 To Sartre, anger, like depression, involved a pathological transformation of the instrumental, differentiated world of cause and effect, which underlies normal mood and is governed more or less by reason and the recognition that there is a connection between what happens to us and how we think, feel, and act.

 In a differentiated world, we selectively respond to that world’s multiple invitations: choices are made, projects are undertaken, goals are set, risks are taken, a certain amount of frustration and pain is tolerated, and gratification is deferred.

, President Barack Obama describes how he forged his personal and political identities in circumstances that were often adverse.

 From the following brief commentary on Obama’s efforts to define-and differentiate-himself, we can get a better idea of what Sartre meant by differentiation: “To say that [Obama] is constructing himself sounds pejorative, but he is open to the world in a way that most Americans have not had the opportunity to be. This is something that outsiders have to do. But, as he evolves, the African American pathway is the pathway to service, to success, and to a more complete self-definition.”

 During the 2008 presidential campaign, Obama signaled his commitment to working in a differentiated, instrumental world of cause and effect when he made it clear to his staff that there would be “no drama with Obama.”

Sartre was not the only existentialist to grapple with the concept of differentiation. To Karl Jaspers, differentiation meant “the breaking up of vague experiences into several well-defined ones, thus giving richness and depth to the total experience. Low-level individual phenomena differentiate into higher ones; the vague instinctive life gains in content. Increased differentiation brings increased clarity and awareness. Undefined intuitions and feelings give place to clear, definite ideas.”

Jaspers, like Sartre, believed that failing to differentiate one’s experience has dire consequences. “From an undifferentiated state of innocence,” he insisted, “emerge the innumerable contradictions and conflicts of our psychic life.”

 To Socrates, the unexamined life was not worth living. To Jaspers, the undifferentiated life was a lesser, pathological life.

Transforming one’s world through pathological emotion

The often implicit commitment to live in an instrumental, differentiated world of cause and effect is a contingent one and can be withdrawn at any time. In the face of disappointment, loss, betrayal, or defeat, a person may deem it too difficult to move forward in an instrumental way and find reasons not to take the steps that would lead to working through and transcending a negative experience by making what Sartre called a “magical transformation” of his experience. This changes the nature and blunts the acuity of the instrumental differentiated world that is a prerequisite for normal mood.

Sartre used the word “magical” to describe the de-differentiating, world-flattening transformation that drives someone who is in the throes of a negative experience toward a regressive and often childlike depressive response. “Magic” derives from the Greek for wizard, and implies trickery. Sartre believed that a “trick” of self-deception-the lie we tell ourselves-is at the heart of the depressed person’s transformed experience, as the unacknowledged refusal 

The depressed person’s “attitude of excuse,” as Sartre called it, seems less inevitable once we recall the concluding words of Samuel Beckett’s novel 

 How do we really know what we are capable of doing when the chips are down? Psychiatry has had little to say about the inherent capacity of people-those whose behavior is within the normal range or those in whom mental disorders have been diagnosed-to use their free will to shape their experience. Psychoanalysts believe that depression entails a decathexis from the world, a notion that seems compatible with Sartre’s magical transformation. Emphasizing both the weakened grasp that depressed persons have on their environment and their implicit efforts to manipulate that environment, George E. Vaillant, MD, noted that “depression, like a child’s tears, is often designed to get someone in the dysthymic person’s environment to 

 In depression, agency is always partially surrendered to others.

Depending on the strength of the magical transformation and the degree of de-differentiation associated with it, one could imagine episodes of depression spanning the spectrum of mild, to moderate, to severe, to treatment resistant. The magically transformed world can also be seen as fertile ground for the psychotic distortions, particularly paranoid delusions, which are sometimes experienced by those who are severely depressed.

In the face of disappointment, loss, betrayal, or defeat, a person may choose (without necessarily realizing it) to become angry. Depression and anger are rooted in the power of a biologically sustained consciousness-

the capacity of the self as active agent, making use of its freedom to choose one option over another to construct its own world

-to replace rational instrumentality with magical thinking.

It is clear that what angers some people leaves others unaffected. Anger does not arise from situations that are inherently anger-provoking, but derives from the way a person constructs those situations. Shakespeare’s Hamlet recognized that “there’s nothing either good or bad, but thinking makes it so.” Anger lasts only as long as someone continues to construct a particular situation angrily or, put another way, as long as one refuses to 

 being angry and continues to indulge in that emotional regression.

Everyone’s life holds enough disappointment and loss so that even the psychologically strongest people occasionally succumb to the pressure of transforming aspects of their experience into depression and anger. For brief periods, we all make use of magical transformations as we refuse to deal authentically with adverse events. This is why we transiently feel “down” or “pissed off.” When someone says, “I’m fighting depression,” it is likely that what is being battled is the altered, oppressing structure of the depressed person’s de-differentiated world. Those with sufficient psychological strength soon return to the instrumental world because, all things considered, life is better for them there. We all face a constant challenge to resolve depressed and angry feelings 

these emotions reach a pathological stage.

Sartre saw anger as an attempt to reduce the tension inherent in a difficult situation by redefining the situation so that a less demanding solution could be found.“It is easy to understand the fit of anger which seized me when I could no longer reply to someone with whom I had been bantering… It was a matter of carrying on the discussion on another plane: I was unable to be witty; I made myself formidable and intimidating. I wanted to inspire fear. At the same time, I used derived (ersatz) means to conquer my opponent: abuse and threats which were 

 the witticism I could not find, and, by the abrupt transformation which I imposed on myself, I became less exacting in my choice of means.”

Anger changes the nature of the game. Going from the instrumental world of normal mood to the magically transformed world of anger involves what Sartre calls the “breaking of one form [the instrumental, differentiated world] and the reconstitution of another [the magically transformed, de-differentiated world].” Only consciousness, he insists, “by its synthetic activity, can break and reconstitute forms ceaselessly.”

 Clearly, the mind is calling the shots here, while synergistically, the brain’s neural substrate changes in response. (Sartre’s reference to 

described by Helen Markus and colleagues,

. Schemata are structural units of self-representation that include a representation of the world.)

Corrosive, debilitating, and destructive anger is a particularly appealing defense for those who live in what the existential psychiatrist Viktor Frankl

 called an “existential vacuum” or “inner void,” where life is meaningless and empty. Angry words and destructive acts are often used in a defensive attempt to fill that void.

 (One of anger’s roots is from the Latin 

, which means to strangle.) Anger can also be used to create what Erik Erikson

called a “negative identity”-if you cannot be good, at least you can be very bad-by someone who decides that it is too difficult to remain in a rational, instrumental mode. Anger is a fall from a higher state of being, a transformation that leads to the degradation of self and the abuse of others. Angry people acknowledge as much when they admit, “I lost my temper” or “I lost it.”

Anger is a heightened state and can energize someone rendered lethargic by depression. Anger has even been called an “antidepressant.” (In 

, Freud said that depression was anger turned inward.

) A depressed person might angrily lash out in an attempt to correct the first structural transformation (depression) with a second transformation (anger). Indeed, the pathophysiology of anger and depression appear to be distinct: persons experiencing anger show hypofunctionality in the ventromedial prefrontal cortex and the amygdala while depressed persons show hyperfunctionality in these areas compared with controls.

 Ultimately, the play-off of anger and depression fails to yield a normal mood as a person cycles through a spectrum of self-induced pathological emotions, which some clinicians wrongly diagnose as bipolar disorder.

Severe chronic anger can come to dominate a life. Alec Baldwin’s former father-in-law has said publicly that Baldwin’s almost constant anger was a factor in the breakup of his marriage to Kim Basinger. An angry voice-mail message that Baldwin left for his daughter, Ireland, after she did not return his repeated phone calls became media fodder. The actor later acknowledged his mortification over his loss of control and profusely apologized.

On February 29, 2008, while I was taking a break from writing this article, an 11 pm news program showed Kevin Borseth, University of Michigan women’s basketball coach, at a press conference that immediately followed the Wolverine’s 69-67 loss to the University of Wisconsin. The Internet posting for the story read in part: “[Borseth] started things off by slamming the podium and saying, “That’s how I feel.” Then he screamed into the camera, “I’m so damn sick and tired of getting out re-bounded.” Things went downhill from there.

To coach Borseth, at the time, other possible ways of processing this loss may have seemed more difficult and less gratifying than making a Sartrean magical transformation. Someone considering Borseth’s decompensation from the cognitive-behavioral perspective would probably conclude that the coach felt the game had not gone as it 

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René J. Muller, PhD

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