Have you ever seen real psychological phenomena

Clinical diagnoses as social constructions

Volkmar Aderhold

Psychotherapy Science 8 (1) 25–32 2018

www.psychotherapie-wissenschaft.info

CC BY-NC-ND

DOI: 10.30820 / 8242.05

Summary: Diagnosis manuals of the past decades caused or intended a progressive de-contextualization of mental disorders, which went hand in hand with the progressive biologization of psychiatry, which ultimately serves the pharmaceutical industry rather than the patients. The findings of biological psychiatry are anything but encouraging, especially because the diagnostic categories are not valid enough. The new system of the Research Domain Criteria (RDoC), which is based on functional neural subsystems of the healthy brain, could advance neurobiology. It is not foreseeable whether this will succeed.

Clinical diagnoses, on the other hand, should primarily serve to facilitate understanding and communication. Since they are basically the result of a social construction process, a dialogical co-construction with the meaningful others in the social world of the person concerned should be the focus. What is necessary and inevitable is an internal and external polyphony of these constructions of reality. Expert psychotherapeutic knowledge is part of this polyphony.

Keywords: Psychiatric diagnoses, ICD, DSM, comorbidity, de-contextualisation, biologisation, Research Domain Criteria (RDoC), diagnosis as a dialogical process, polyphony

What "are" mental illnesses? Doubts about the validity of psychiatric diagnoses

Mental illnesses and their diagnostic classification are a social and specialist social construction. The symptoms, which serve as criteria for the classification, are dimensionally distributed as phenomena in a population, that is, the boundary between normal range ("normality") and deviation ("mental illness") is an arbitrary setting based on conventions. Diagnoses thus give psychological phenomena that lie outside of a statistical norm an apparently categorical order, but are produced and made solely through the clustering of phenomena. These clusters do not take into account any causes of any kind, i.e. neither neurobiological and biological starting points nor context factors, cultural conditions or interactional factors. The phenomena lose their reaction character and are thus rendered characteristic. Diseases “break out” or “exacerbate” according to a supposed biological law. As a result, people who are described as mentally ill are perceived and treated in a more reified manner.

Defining mental illnesses is delegated to experts in modern societies. Symptom-centered diagnoses are the result of a ritual that is considered necessary to be recognized as a medical discipline. And so psychiatrists are on an equal footing with their medical colleagues. And in this way, they also largely retain control over a subject area for which other disciplines, above all psychology and psychotherapy, could make “claims to dominance”.

A major goal of the ICD-10 and DSM-IV and their further development was in the mid-1990s to make diagnostic practice comparable internationally and, above all, between scientific studies. It is true that this led nationally and internationally to better reliability of diagnoses in scientific clinical studies. In field studies on the use of the DSM-5 in everyday practice, however, the reliability of the diagnoses was consistently weak, often no better than with the old diagnostic systems (cf. Freedman et al., 2013). The further development of the diagnostic manuals was even accompanied by serious undesirable developments, as will be explained below.

Cultural differences were leveled out by the diagnostic manuals. The fact that indigenous perspectives and explanations have been suppressed and the pharmaceutical industry has been able to open up further markets is seen as colonization, which often produces more disadvantages than advantages for the population of the newly "developed" countries (cf. Summerfield et al., 2008; Watters, 2009 ).

"Comorbidity" is suggested by the fact that earlier, meaningful rules of diagnosis have been overridden. The undesirable developments include: the abandonment of the hierarchy and layer rule when diagnostic categories overlap; incorrect interpretation of diagnostic terms due to missing or imprecise definitions; the so-called polythetic approach, according to which only a minimum number of diagnostic criteria must be met for the diagnosis; fuzzy distinction between additional symptoms and comorbid disorders; Disregard of exclusion criteria; Inclusion of successive (longitudinal) and simultaneous (cross-sectional) symptoms. The resulting impression that there are high rates of “comorbidities” contradicts the fact that the diagnoses in no way depict independent underlying diseases.

A purely cross-sectional view of the symptoms also leads to frequent changes in diagnoses if symptoms appear or disappear, or if only the patient's report on the symptoms changes.

The observer dependency of the diagnoses, which was criticized earlier, was not reduced, but only more veiled by the apparently increased objectivity. It may be aggravated by insufficient psychopathological competence, subjective preferences, countertransference phenomena, but also strategic considerations. This includes both fraudulent “upgrading” for economic reasons and “downgrading” to minimize stigma. Diagnoses are also used to bill psychiatric services. As far as the validity of the diagnoses is concerned, top performers are largely unconcerned.

With the introduction of the DSM-5, the structural validity of the diagnostic constructs was lost even further. What is actually hidden behind a cluster as an independent disease category remains inaccessible or is lost in the continuing great heterogeneity within the syndromes. This is presented as an intended and beneficial "etiology independence".

For this reason, Thomas Insel, at the time Director of the National Institute of Mental Health (NIMH), announced two weeks before the publication of the DSM-5 that the NIMH would withdraw its support for the manual and would not fund any research that exclusively focused on DSM-5. Diagnoses are based. He justified this with the inadequate validity of the DSM-5 and the hodgepodge of symptom descriptions it contained. The patients deserved better. He compared this type of psychiatric diagnosis with a practice in somatics, in which different types of chest pain without an assignment to the cause are used as sufficient diagnoses (see Insel, 2013).

The changes in the diagnostic categories and the criteria within the clusters are large across the various versions of the diagnostic manuals. The attempt by the DSM-5 to rearrange diagnoses also makes this clear again.

The diagnosis of "schizophrenia" shows particularly clearly how arbitrary the attempts to organize the diagnosis manuals are. Historically, for example, the intersection of the symptom clusters used for schizophrenia between its invention by Bleuler (1911) and 1984 has been 27 percent, i.e. over 70 percent of people who are so defined in one system would not receive this diagnosis in another diagnostic system (see Katschnig, 1984). For those affected, however, it is of crucial importance in terms of their life whether they receive this diagnosis or not.

With the DSM-5, the subgroups of schizophrenia according to Bleuler (1911) - hebephrenic, catatonic, paranoid and undifferentiated - have just been abolished because of their poor stability, reliability and prognostic relevance. Likewise, Kurt Schneider's symptoms of the first order are no longer used as criteria. Schneider had originally (1938) only assumed this heuristically, but for decades they were considered "pathognomonic", that is, sufficient for a reliable diagnosis. After more than 70 years, they have not been empirically confirmed. Late empiricism for an allegedly evidence-based scientific diagnosis!

In the ICD-10 and probably also in the upcoming ICD-11, four weeks of symptoms are sufficient to diagnose schizophrenia, whereas in the DSM it is six months. This is a major difference that remains between the expert groups even after three revisions. This again shows how arbitrary decisions are made - decisions that nonetheless have serious consequences for many clients.

Interest-based approach

Professional societies rely on scientific evidence when defining diagnostic units, but in fact the decision-making is made through majority votes - and these are interest-based. Because the majority of those who vote participate in the lucrative pharmaceutical lobbyism with annual fees of up to seven figures. Many claim that they cannot be influenced because they receive fees from several companies.

Most clusters that denote psychological deviance are subject to cultural norms and have been influenced by the marketing interests of the pharmaceutical industry for decades.

For example, initiatives by the pharmaceutical industry in Japan ensured that minor depression previously experienced as not pathological became available for SSRI prescription after the introduction of SSRI-type antidepressants. The fact that antidepressants are hardly superior to placebos in mild and moderate syndromes (NNT1 = 10) and that these syndromes remit even without medication could only be demonstrated later in meta-analyzes, based on the "freedom of information act" (US Congress 2005) also unpublished studies with negative results could be evaluated:

«In a meta-analysis in which studies with direct comparisons between open psychotherapy and open pharmacotherapy of depressive episodes were evaluated, there was a significant, but in relation to the absolute number of patients, slight superiority of antidepressants over psychotherapy (NNT = 14) (Cuipers et al. , 2015), so that the authors themselves come to the conclusion that the differences identified here cannot be regarded as clinically relevant ”(S3 NVL Unipolar Depression, Version 3, 2015, p. 19).

The following therapy recommendation is therefore downright misleading: The current care guideline for depression (2016) simply summarizes moderate and severe depression in the “Pharmacotherapy” section (cf. ibid., P. 66). In the case of moderate depression, for which there are hardly any benefits of pharmacotherapy in comparison with placebo (NNT = 10), apparently as many people as possible should also be treated with antidepressants in accordance with the guidelines.

In Germany, SSRIs are being prescribed more and more frequently for depressive syndromes without, for example, a shortened incapacity for work after pharmacotherapy was ever recorded by the health insurance companies. Since the prescriptions of antidepressants in Germany have increased by 680 percent in the past 22 years and there has also been a further doubling in the last nine years, more and more natural reactions to life experiences must have been medicalized, because an increase in the severity of the psychological Diseases (SMI) cannot be scientifically proven (cf. Richter et al., 2008).

In a survey of 1,683 people treated with antidepressants, 65 percent said they had previously experienced one or more stressful events or circumstances such as relationship problems (19%), life transitions (19%), losses (18%), problems at work (15%) ), other health problems (15%) and less often social isolation, abuse, violence, financial problems (see Hartdegen et al., 2017). This is an example of how de-contextualizing diagnostic categories should pave a direct and difficult to correct path into pharmacotherapy and - in the interests of the pharmaceutical industry - should pave it too.

In the study, the effectiveness of antidepressants was positively correlated with the assumption of biogenetic causes of one's own complaints.

The idea of ​​a chemical imbalance (which has not yet been scientifically proven) as the cause of the complaints correlated in turn with the quality of the relationship with the prescribing doctor (see Read et al., 2015).

If you combine antidepressants with psychotherapy, in many cases - at least implicitly - there is competition between the explanatory models and the professionals involved. Since antidepressants work largely through placebo effects and thus attribution, they need a biological explanation to be adopted. This must necessarily weaken many psychotherapeutic factors. Can effective psychotherapy also weaken the placebo as an active factor?

Medicalization also exposes patients to unpredictable side effects. The longer the intake, the more and stronger. In the survey cited, more than half of them take longer than three years. The most common side effects were sexual difficulty (62%), emotional numbness (60%), feeling not yourself (52%), a decrease in positive feelings (42%), less caring for others (39%), suicidality (39%) and withdrawal symptoms (55%), which often make complete withdrawal impossible (see Read et al., 2014). Obviously, these are also side effects that prevent psychotherapy from being successful.

Further increases in prescriptions are even possible with neuroleptics - despite many alarming findings about their harmful side effects. In addition, more recent studies show a significantly lower demonstrable effect with an increase in NNT from 3 to 4 in the past to 6 today.

Increases in drug prescriptions can also be seen in generalized anxiety disorder, ADH syndrome, bipolar disorder in children and adolescents - and in the near future probably also in grief reactions which, if they last longer than four weeks, are also assessed as pathological so that antidepressant therapy is recommended.

De-contextualization and biologization of psychological phenomena

The good intention and the good purpose of making the diagnosis independent of the theoretical orientation of the diagnostician has turned into the opposite: With the theories, the psychosocial contexts are also lost sight of. And although today's diagnoses seem to be independent of the cause, the diagnosis often leads to an implicit and explicit biologization and “geneticization” of the syndromic constructs. Both have disadvantages. This de-contextualization often leads to the diagnosis having unfavorable or the wrong consequences for the affected people. Because too often, biologization paves the way for primary or even exclusive pharmacotherapy. In the following I will go into the disadvantages in detail.

Primacy of pharmacotherapy

Biologization primarily serves to pharmacologize psychiatric treatment. Syndromes are defined in such a way that they become accessible to specific pharmacological interventions. Shame, for example, becomes accessible to antidepressants through generalized anxiety disorder, "rebellious" behavior of children through bipolar disorder to antipsychotics, and a longer grief reaction to antidepressants. The generic names of psychotropic drugs suggest a diagnosis-specific beneficial effect. Often - completely misleading - an analogy is made to treating diabetes with insulin:

“A person suffering from psychosis in an acute situation has a problem with the neurotransmitter dopamine. These people then need a drug, just like a patient with high blood sugar needs insulin. Talking doesn't go away »(Falkai, 2013).

Alleged “incomprehensibility” of behavior

The more the societies that use international diagnoses differ from the (post) industrial societies, the less culturally compatible these diagnoses are. In addition, they alienate people from other social / ethnic concepts of understanding and action. In this regard, the shamanic concept of an "initial call" is known, which phenomenologically often corresponds to a first psychotic episode, and the obsession with ghosts, which is answered with a ritual for the person concerned and his family or the village community.

forecast

Diagnoses do not allow for an even remotely reliable prognosis. From recovery to chronification, everything is usually possible. Nevertheless, diagnoses often become a self-fulfilling prophecy, in that they usually cause negative visions of the future in those affected and relatives, but also in professionals.

Stigma

Diagnoses are often stigmatizing and, less often, relieving. The attempt to reduce the extent of the stigmatization of mental “illnesses” through their biologization has probably failed. With the social expansion of diagnoses with invented biological explanatory models, social stigmatization tends to increase, not decrease.People with brain disorders experience greater social rejection than people who have fallen into psychological crises due to negative life experiences. They seem stranger to us, more incomprehensible and uncontrollable in their actions - and so do themselves (see Angermeyer et al., 2014). Diagnoses, which should exercise a medical-humanistic protective function against excessive demands and rejection, turn into their opposite.

Placebo studies and animal research, however, suggest the great importance of positive expectations and hope for neuroplastic processes, especially among psychotropic drugs. Under negative expectation conditions, psychotropic drugs can also have a negative effect (nocebo effect, see Rief et al., 2016).

Biological arguments against biologization

Up to now, diagnoses cannot be confirmed by unambiguous biological phenomena (biomarkers). For example, to this day - even after 40 years of imaging - there are no consistent and reliable anatomical and functional changes that can be clearly assigned to clinical observations in people with a diagnosis of schizophrenia or that would have led to changes in treatment (cf. Fusar-Poli et al., 2016, p. 2011). Evidence that schizophrenia is a disease of the brain has not yet been provided. Griesinger's dictum "Mental illnesses are brain diseases" should urgently be shelved. To date, no useful neurobiological explanations have been found for depression either. The “chemical imbalance” theory is now obsolete. Even if neurobiological substrates can be found sporadically, they are almost always just an intermediate link in a long chain of transmission with an unclear beginning. For example, regionally increased dopamine in psychotic phenomena is certainly not the “cause” of psychoses, but only the common “pathophysiological final stretch” (Howes et al., 2009) of various other living conditions associated with stress and trauma (cf. Varese et al ., 2012), the possible genetic component of which has not yet been clarified (cf. Johnson et al., 2017).

Many psychological phenomena can be assigned to several different disease categories as symptoms, and there are hardly any genetic or neurobiological findings that cannot be assigned to several categories. Psychological phenomena can therefore by no means be explained by genetic or neurobiological findings. Both phenomena are relatively independent of each other:

"Looking for the neurochemistry of mental disorders that don't necessarily exist has turned out to be as futile as using a map of the moon to get around Manhattan" turned out to be as pointless as using a map of the moon in Manhattan to orientate yourself »] (Greenberg, 2013; translation by VA).

In addition to biological determinism, there is often a more or less pronounced genetic determinism. Today it has been proven that gene-environment interactions are far more complex than the still widespread 50/50 percent attribution to genes and the environment would lead us to believe. Genetic factors are more often controlled by environmental experience (epigenetics). The promises were great 20 years ago, but real therapy-relevant advances in genetics have not yet been recorded. The geneticists themselves attribute the stagnation in research to the fact that there are no valid and sufficiently homogeneous diagnostic constructs to date, which means that the heterogeneity is too great even within a diagnostic category. In people with a “schizophrenia diagnosis”, the genetic determinants are now suspected to be in individually different polygenetic clusters and individual nucleotide polymorphisms (SNP), each of which, however, has only minimal effect sizes. Genetic and neurobiological findings either apply to several diagnostic categories or only to sub-syndromes. No other diagnostic categories are in sight.

Current crisis in psychiatry

The jug goes to the well until it ...

Psychiatry has maneuvered itself into a situation that is characterized by great uncertainty and instability. The neurobiologization of psychiatry project has so far not been able to produce any results with solid evidence: diagnostics, genetics, causal biological mechanisms, causal pharmacotherapy, sufficient effects of pharmacotherapy, reduction of the tendency to chronicity, and effective pharmacotherapeutic early interventions do not exist. Valid syndromes that are determined by specific neurobiological processes cannot be derived from symptoms alone. On the other hand, no consistent diagnostic classifications can currently be derived from the neurobiological findings. This gap is to be closed by new basic diagnostic criteria.

So-called Research Domain Criteria (RDoC) should apply as the basic categories. They represent the beginning of a new system of order for basic science. This system is completely unaffected by existing diagnostic categories, but is based on the neural systems of the healthy brain. The RDoC are:

  1. Negative valence system (aversive motivation / fear)
  2. Positive valence system
  3. Cognitive system
  4. System for social processes
  5. Arousal / regulatory system

Genetic, imaging, physiological and cognitive data are then assigned to the RDoC in order to gain further knowledge from this synopsis. However, these data are no longer delimited or excluded by diagnoses. These clusters should then be related to symptoms and treatment effects. This project will take many years to decades. It is unclear whether it will be successful. Well-known scientists are already expressing considerable doubts (for example by Fava, 2014). The NIMH, on the other hand, is enthusiastic. In principle, the scientists can continue as before, only the findings are refined and they are assigned to each other differently.

Basically, the brain as a social organ is in opposition to such concepts. Social experiences are largely decisive for cognitive, affective and relational learning and development processes. With regard to the development of psychological phenomena that deviate from the norm, further negative social events and processes are of decisive importance. Whatever the inherited genetic disposition, it is probably never sufficient to determine significant abnormal syndromes. It is probably the other way around: Even very early social experiences seem to retrospectively modulate genome function, for example through DNA methylation.

For example, the following social factors have been identified for psychoses and have already been replicated: biological and psychological pregnancy complications, birth complications, early experiences of loss, early unstable environments, parental conflicts, sexual, physical and emotional trauma, neglect, growing up in cities, social fragmentation, social emergencies, social rejection and defeat, bullying, discrimination, migration, cannabis.

This deconstructive presentation of “invalid” constructions of illness is intended to be encouraging. The fragile structure of mental illness is only poorly stabilized by a framework of diagnostic and pharmacological habits. This psychiatry should be faced (more) unabashedly. The emperor has long since worn out of clothes. Psychotherapeutic action should by no means be tied to these disease and diagnostic constructs.

The neurobiological recourse to the basic dimensions of the RDoC described above is intended to encourage, in the area of ​​psycho-social-spiritual understanding, to fall back on meaningful, orientation-giving approaches to understanding that we already have and that need to be further developed. It would be time for them to step out of their shadowy existence and close the gaps that neurobiological research has left or created so far with their understanding and explanatory power.

Diagnoses as a dialogical de- and re-construction

Diagnoses remain historically shaped, i.e. transitional phenomena. The fact that neurobiologically oriented scientists construct new systems in the expectation that they will later be able to explain psychological phenomena that have been defined as deviating does not change this. One can be curious and justifiably skeptical: however the findings are correlated and categorized, one will not find any causes, but rather accompanying circumstances, neural correlates or links in the mechanisms of development of psychological phenomena as an expression of living self-organization.

If one takes the increasingly complex and increasingly socially determined neuroscientific findings on consciousness, self-awareness and the experience of reality seriously, one becomes much more modest and cautious in expectations. Obviously we are not in contact with subjectively experienced realities, but only with inner representative structures for the world and ourselves. However, we do not have direct contact with an outside world through sensory perception. It only appears to us that way, so-called phenomenal representations in the sense of naive realism (see Metzinger, 2013).

The RDoC are therefore an open-ended effort that will probably take ten years or more to complete. It is not to be expected that the current diagnostic systems will be abandoned by then. So you have to find a strategic way to deal with them, but not take them too seriously. This is usually easy to discuss with those affected. It often makes sense to ask them how they would like to deal with diagnoses.

Clinical diagnoses should be used for understanding and communication. Since they basically represent attributions and can set in motion a strong tendency towards identification, reification, potential self-alienation or even rejection and maintenance of this attribution through institutional, social and individual adaptive processes, caution is required. The fact that diverse stressful, pathogenic, traumatizing social processes are personally located and thus characterized, diagnoses continue to lead to a mainly individual attribution of the social, cultural, societal and economic factors. People tend to adopt external ascriptions in their own self-image and behave accordingly (cf. Wiesner et al., 2016; Hacking, 2006). It would therefore be important and a great opportunity for those affected to consistently examine psychological phenomena for their relational character. They are almost always an expression of a relationship event. But this way of looking at things would still be too weak to do justice to the intersubjective construction of realities.

Every psychiatric diagnosis is the result of a social construction process that intersubjectively constructs not physical, not even biological, but psychological and social phenomena. The context and observer dependency of psychological phenomena must therefore be taken into account consistently. Everything is always said by a specific observer and only applies in the examined contexts. Diagnoses are made in the language and current thought patterns of psychology and psychiatry. The process of constructing these diagnoses derives its justification from its therapeutic function. In the best case, the diagnostic process leads to a feeling of being understood and self-understanding, in the worst case to a feeling of stigmatization and discrimination.

For therapeutic action, names of differently experienced or defined psychological phenomena must be helpful and not hindering or even destructive. This means that different demands are placed on diagnoses. They should be aware of their historical transitional character and should therefore not be viewed as true, but in the best case as useful. They should serve the individual and intersubjective understanding and being understood, whereby the other is not only the professional other, but also the other relevant to the world of life are to be included. The individual should be understood as a social individual in a context that co-constructs subjective realities and self-experience. This is made impossible by adding up symptoms that must be partial and intermittent. Understanding can only be achieved through individualization and not through classification and categorization.

At the beginning of the diagnostic process there is an individual description. This, however, is a dialogical event, so it always includes the other, changes through the other, solely due to the complexity. The psychological and social phenomena in question are fuzzy, vague, ambiguous. This intersubjectivation and the dialogical co-construction in a diagnostic process with the meaningful others in the social world of the person concerned should be in the foreground instead of professional extraction and abstraction. What is necessary and inevitable is an internal and external polyphony of these constructions of reality. Everyone necessarily sees only part of it, the other sees it differently than we do, and we usually see it differently at different times and even at the same time. Psychiatric expertise is part of this polyphony. The diagnostic construction process would accordingly be part of the natural environment, multi-perspective and multi-dimensional. In the dialogical process, diagnostics and therapy could hardly be separated. A prototype of a dialogical-diagnostic-therapeutic process would be network discussions of the most important protagonists. They contain:

  • subjective and intersubjective phenomena,
  • Descriptions instead of definitions, rather vague and ambiguous,
  • Context conditions,
  • Development history, development conditions,
  • Reconstruction of the meaning and significance of significant life experiences / events,
  • Effects in everyday life and living environment,
  • Process-like nature of the phenomena, time limits, episodes in the language of psychiatry,
  • Consideration of the high natural adaptability of individuals and systems,
  • Resources,
  • Reasons and conditions,
  • intersubjective meanings,
  • inner penetrance of the phenomena (how strong do I have them? am I them?)

Psychological crises are re-contextualized in the identity and the biographical self-image. Diagnoses then become part of narratives, more in the sense of language images (metaphors) instead of fixed categories.

These constructions should be process-open and hermeneutically diverse and non-lockable in order to avoid inappropriate identification with a construction. Presumably, with such a procedure, many syndromes could be weakened or largely resolved again in the process of communication after months.

It remains to be seen whether such an understanding, dialogical, intersubjective process could find a connection with the neurobiological constructions. Both remain basically different accesses with different ranges. In recognition of the other, both explanatory and understanding access are justified for an indefinite period of time. In this way, current psychiatry could again dare to take a more searching, ethically also experimental approach in therapeutic, understanding and explanatory contexts.

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Clinical diagnoses as social constructs

Diagnostic manuals of recent decades intended or effected an ongoing de-contextualization of mental disorders, which went hand in hand with the advancing biologizing of psychiatry, that ultimately served the pharmaceutical industry rather than the patients. Moreover, the findings of biological psychiatry are far from encouraging, notably because the diagnostic categories lack validity. The Research Domain Criteria (RDoC) constitutes a new research framework that is based on functional neural subsystems of the healthy brain and may advance neurobiology. It is not foreseeable whether this approach will succeed.

The first and foremost objective of clinical diagnoses, on the other hand, should be understanding and communication. Since they are fundamentally the result of a social construction process, the primary focus should be on co-constructing through dialogue with the significant others in the social environment of the person concerned. Accordingly, an inner and outer polyphony of these constructions of reality is necessary and inevitable. Psychotherapeutic expertise also forms a part of this polyphony.

Keywords: Psychiatric Diagnoses, ICD, DSM, Comorbidity, De-contextualization, Biologizing, Research Domain Criteria (RDoC), Diagnosis as a Dialogue Process, Polyphony

Diagnosi clinica come costruzione sociale

I manuali di diagnosi degli ultimi decenni funzionano e propongono una progressiva decontestualizzazione dei disturbi psichici, la quale è andata insieme a una progressiva biologizzazione della psichiatria, che alla fine serve più l’industria farmaceutica dei pazienti. A riguardo la conoscenza scientifica della psichiatria è tutt’altro che incoraggiante, in particolare anche perché le categorie diagnostiche non sono sufficientemente valid. Il nuovo sistema di Research Domain Criteria (RDoC), che deriva dai sottosistemi neuronali funzionali del cervello sano potrebbero far progredire la neurobiologia. Se ciò riesca, è da vedere.

Le diagnosi cliniche per contro devono servire prima di tutto alla comprensione e all'informazione. Poiché esse fondamentalmente sono il risultato di un processo di costruzione, al centro di esso dovrebbe trovarsi un dialogo di co-costruzione con gli altri attori significativi nel mondo sociale dei soggetti. È quindi necessaria e inevitabile una polifonia interna ed esterna di costruzioni di verità. Il sapere psicoterapeutico fa parte di questa polifonia.

Parole chiave: diagnosi psichiatriche, ICD, comorbidità, decontestualizzazione, biologizzazione, Research Domain Criteria (RDoC), diagnostica del processo dialogico, polifonia

The author

Volkmar Aderhold, Dr. med., is a doctor for psychiatry, psychotherapy and psychotherapeutic medicine as well as a teacher for systemic therapy and counseling (DGSF). He has been working in psychiatry since 1982, 10 years of which as a senior physician in the Clinic for Psychiatry and Psychotherapy at the University Medical Center Hamburg Eppendorf. He is currently an employee of the Institute for Social Psychiatry at the University of Greifswald and works through lectures, publications and advising psychiatric organizations in the field of structural development.

Contact

[email protected]