The big book
Psychiatric Diagnosis as a Cultural Phenomenon
Today I want to clarify for those who are not familiar with the underlying substrate shakily holding up the institution of diagnosis. The large American bible of diagnosis is known as the DSM-5, the Diagnostic and Statistical Manual, version 5. This manual is the source of all diagnoses, which are required of psychotherapists for all third party payment and for many other reasons. Although these diagnoses are revised in keeping with the beliefs and biases of the field, they are far from scientific in any sense of the word. Instead they tend to reflect cultural beliefs and opinions of practitioners based on their own perspectives and on what they believe that they see in their practices.
Why do I say it in this way-that they believe that they see-instead of what they see or experience, which sounds more objective. That is because there is nothing objective about what anyone sees no matter how well trained they are, especially when it involves the complexity of what is a human being. This is not like looking at a bacillus through a microscope. Instead it involves inner and outer contextual complexity of an incredible degree.
Many patients are comforted by a diagnosis and it is increasingly popular to self-diagnose. This magical incantation is a sort of absolution for many. It says “I am not a bad person. I am not to blame. I have an illness called borderline personality disorder or depression or….” While a diagnosis is helpful in many cases that is largely because what it changes is the belief system of the individual. It organizes thought and can help some people in managing symptoms.
However, these are little more than belief systems themselves and many students and interns find themselves in multiple categories as they learn. There is , in general, a great deal of overlap in categories and the diagnostic decision is made by counting “symptoms” in overlapping categories.
During the years of Black slavery in the United States, there was a diagnosis known as “drapetomania,” defined as the irresistible impulse to run away from slavery. Today a psychiatrist would be more likely to diagnose a slave owner, but this is because of a change in culture and not a scientific breakthrough. Until the 1970’s, homosexuality was considered a valid diagnosis. It has since then been removed based upon a change in culture, a strong lobbying effort and a vote by psychiatrists who are member of the American Psychiatric Association. These are democratic diagnoses voted in or out as iif they were diseases, but are not true diagnoses or diseases.
Also in the 1970’s, responding to pressure from the growing number of feminist psychiatrists and psychologists, the American Psychiatric Association slowly and often reluctantly, removed many of the overtly sexist and misogynist diagnoses. After all, it was once widely believed that hysteria, based on a woman’s uterus wandering through her body, was a valid disorder of females.
Today, more promising paths of inquiry exist. These involve different avenues, such as neuroscience and psycho-immunology. Also influential are the kinds of bacteria in the intestines, responsible for what have become known and rightfully so as “gut” feelings. All these approaches are more promising than the perspectives of a few practitioners and are a direct result of advances in technology. Neither science nor social change can advance without technology to make it possible. Also the sciences and professions of the West must come to the understanding that the whole organism interacts constantly with the very complex inner and outer contexts.
This is only a brief introduction to the literature on diagnosis to bring my readers up to speed. Much has been written over the last decades for those interested in delving more deeply into this important topic. In my next blog, I will discuss psychotropic medication, how it is prescribed, to whom and by whom.
 Kaschak, E. The Mattering Map, Psychology of Women Quarterly, 2015.
 Kaschak, Ellyn (1992), Engendered Lives: A New Psychology of Women’s Experience, Basic Books.