Mass Murder and the Flaws of Checklist Psychiatry

Bret S. Stetka, MD; Lars Siersbæk Nilsson, MD


June 02, 2014

Clinical Implications

Medscape: What are the clinical implications of your work for practicing psychiatrists?

Dr. Nilsson: I think the recent and rather heated debate over the revision of the DSM clearly illustrated that we are faced with severe diagnostic problems. And it seems to be that this crisis of both clinical and academic psychiatry is encapsulated in the disagreement on the mental state of Breivik. I also think that the historical aspect of our study makes it painfully clear that the so-called operational revolution has not resolved these issues. Ongoing problems with comorbidity and the volatile incident rates of disorders such as ADHD and borderline personality disorder testify to the fact that we still deal with massive validity and reliability issues. Moreover, the hope for the imminent emergence of biomarkers that would ultimately render in-depth clinical psychopathology superfluous has, so far, proved to be a vain one. As it has been pointed out by prominent psychiatrists such as Nancy Andreasen, the net result seems instead to have been a general impoverishment of psychopathological knowledge as the diagnostic manuals have become the sole and undisputed authorities on all things psychopathological.

It seems to me that the only way to safeguard our profession against the reductionist reading matrixes that the DSM-5 or ICD-10 comprise per se is a renewed interest in phenomenological psychopathology. If we are to avoid idiosyncratic diagnostic habits, we need to develop an eye for context and Gestalt. The primary psychiatric object continues to be the disturbed subjectivity -- the experience and expression -- of our patients, and this cannot be exhaustively or adequately accounted for by checklists.

But I also think there is a growing appreciation of this within the psychiatric community. There is an increasing interest in the work done at our facility under the supervision of Prof. Josef Parnas and like-minded colleagues abroad who experience the same thing. I truly think this is the only way forward for a psychiatry that strives for both validity and reliability.

For more information on the work of Dr. Nilsson, please visit the Examination Of Anomalous Self-Experience and University of Copenhagen Center for Subjectivity Research Websites, or email Dr. Nilsson directly. Additionally, Dr. Nilsson and colleagues will present their study at a symposium as part of the upcoming World Congress of Psychiatry in Madrid, Spain.


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