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

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.

Editor's note: 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 can be read by clicking here.

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.

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.

Understanding and Explanation
In his classic, often-revised treatise General Psychopathology, the German existential psychiatrist Karl Jaspers, MD, distinguished 2 ways of knowing: Verstehen, which translates into English as understanding, and Erklren, which translates as explanation. 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: Verstehen), and the natural sciences (quantitative psychology, chemistry, and physics: Erklren). Jaspers’s use of this distinction in psychiatry helps us to see why understanding, even without explanation, can set the clinician on the path to a correct, if incomplete diagnosis.

With understanding, 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.1

What Jaspers says here about understanding comes down to knowing a phenomenon subjectively by intuiting its essence. In contrast, explanation designates a more objective way of knowing, based on empirical study, which attempts to disclose the cause 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, MD2 has pointed out. Jaspers’s epistemological distinction between understanding and explanation 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 explained in the Jasperian sense, and that the fullest understanding that can be had is “explanation” enough.

The DSM Shorts Understanding for (Putative) Explanation
The DSM-III became the standard for diagnosing psychiatric disorders during a time when neuroscience, the science of the brain, was producing data that were expected to explain 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.”3

In effect, the DSM-III allowed that, in making a diagnosis, a clinician didn’t have to either understand or 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 explain a mental illness, however inadequately, you do not need to understand 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 have that disorder! (For some mental disorders, the DSM-III and DSM-IV 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 Doing Psychiatry Wrong,4 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 An Unquiet Mind.5 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 understands 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 explain 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.

No Understanding, No Explanation, No Valid Diagnosis

One of these patients is a friend of mine. In Doing Psychiatry Wrong, 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 understanding 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 understanding 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 able to specify a biological explanation, 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.”6

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 understood 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.7,8 Again, Michael First:

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.9

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 understanding, 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 personal experience, 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.9 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 explanation for why people develop mental illness, we need to focus on understanding how and why our patients’ lives have gone wrong. This is the only authentic and valid starting point for our therapeutic intervention.




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