COMMENTARY

Positivism, Humanism, and the Case for Psychiatric Diagnosis

Ronald W. Pies, MD

Disclosures

August 20, 2014

In This Article

The Existential-Humanist Perspective

The existential-humanist perspective (EHP) in psychiatry is widespread not only among many nonphysician mental health specialists, but also among many psychiatrists. One radical version of the EHP is the notion that so-called psychiatric illnesses are really nothing more than "problems in living" -- amenable not to psychotropic medications, but to psychological explorations of the patient's worldview, coping mechanisms, spiritual outlook, and social supports.

The most famous proponent of this view was undoubtedly the late Dr. Thomas Szasz. In this passage from his 1960 essay (later, his book) The Myth of Mental Illness, Szasz combines a form of the EHP with a quasi-positivist perspective:

I use the word "psychiatry" here to refer to that contemporary discipline which is concerned with problems in living (and not with diseases of the brain, which are problems for neurology). Problems in human relations can be analyzed, interpreted, and given meaning only within given social and ethical contexts.... The foregoing position which holds that contemporary psychotherapists deal with problems in living, rather than with mental illnesses and their cures, stands in opposition to a currently prevalent claim, according to which mental illness is just as "real" and "objective" as bodily illness...." [17]

For Szasz, as for many existential therapists, so-called mental illnesses are really problems arising from "conflicting human needs, aspirations, and values."[17]

Now, as it happens, I am a long-time proponent of the EHP in general -- that is, of the view that asserts the primacy of personal responsibility; the importance of one's way of "being in the world"; and of the relevance of philosophy, linguistics, literature, and religion in our approach to psychological problems.[18,19] Some of my formative influences included Viktor Frankl, Rollo May, James Hillman, and Karl Jaspers. In very broad terms, these philosophers and psychologists (Jaspers, of course, was a psychiatrist) emphasized not only causal explanations for illness (what Jaspers, following Wilhelm Dilthey, called erklaren), but also psychodynamic and intention-based understanding (termed verstehen).[20,21]

Put in clinical terms: When Mr. Jones is depressed, it's not enough to posit low serotonin levels in his brain (which may or may not be the case). We must understand what gives Mr. Jones's life meaning and purpose, and how these have been undermined by social, psychological, and spiritual impediments in his life.

I heartily agree -- but all this is in no sense a refutation of diagnosis in general, or of psychiatric diagnosis in particular. And no, I do not necessarily mean the categorical diagnostic model found in the DSMs, which admittedly has many problems and limitations, as I and others have noted.[22,23] "Diagnosis"(from the Greek dia-, across, between; gnosis-, knowledge), etymologically, means simply discernment or knowing the difference between one thing and another.[24] We need not use the DSM-5's categories, but we certainly must know and recognize the difference between depression and anxiety; delirium and dementia; mania and hypomania; and psychosis and derealization, among other.

Moreover, we need to recognize that the "problems in living" trope has its own limitations. Consider this passage from writer William Styron's autobiographical book, Darkness Visible:

Death was now a daily presence, blowing over me in cold gusts. Mysteriously and in ways that are totally remote from normal experience, the gray drizzle of horror...takes on the quality of physical pain...[the] despair, owing to some evil trick played upon the sick brain by the inhabiting psyche, comes to resemble the diabolical discomfort of being imprisoned in a fiercely overheated room...there is no escape from the smothering confinement...the victim begins to think ceaselessly of oblivion...the faith in deliverance, in ultimate restoration, is absent... [25]

Note the phrase "totally remote from normal experience." To describe such a severe major depressive episode as a "problem in living" is to trivialize almost unbearable suffering with a vapid euphemism. Styron's condition was disease in as valid and robust a sense as when this term is used in reference to cancer.

Indeed, in a recent piece in Psychiatric Times, pediatrician Dr. Elizabeth Griffin poignantly described her own depressive illness in terms of its profound suffering and incapacity:

I couldn't pay my bills on time. I couldn't clean my house. I lost 60 pounds in a year without trying, because I couldn't eat. I quit opening my mail and answering my phone. I completely isolated myself, and I sat at home weeping.... The time finally came though, when...I could not complete my charts. I could not concentrate. I hid in my office, crying at times..." [26]

Eventually, Dr. Griffin nearly buys a gun and turns it on herself -- but, thankfully, she resists. Still, she writes, "I do think that depression might kill me someday." She beautifully characterizes major depression as "...overwhelming and overpowering: it crushes its prey." For her, as for many severely depressed people, depression is not a mere "problem in living" but a terrifying gateway to dying. Ironically, the EHP, if applied indiscriminately to all psychiatric disorders, is a form of reductionism -- no less procrustean than an exclusive fixation on "brain chemistry" or neurotransmitters.

Of course, not all the problems psychiatrists see and treat are instances of disease. We treat individuals and families dealing with normal grief and loss.[19] We treat adolescents struggling with their sexual identity. We treat some who are simply searching for "meaning" in their lives. But we are also members of a medical discipline, whose patients often suffer from life-threatening illnesses. To be sure, many of them will face ignorance, prejudice, and discrimination when their condition is revealed to others. But this is reason to educate and inform the public, and to advocate in behalf of our patients' vital interests -- not to shirk our medical responsibilities or apologize for our diagnoses.

*Logical positivism (or logical empiricism) holds that a statement is meaningful only if it is empirically verifiable or logically self-evident (eg, the statement, "All bachelors are unmarried males"). For more, see http://www.philosophybasics.com/branch_logical_positivism.html

Editor's Note: A slightly condensed version of this piece was first posted on the Psychiatric Times Website.

Ronald W. Pies, MD, is Professor of Psychiatry and Lecturer on Bioethics and Humanities, SUNY Upstate Medical University, Syracuse, New York, and Clinical Professor of Psychiatry, Tufts University School of Medicine, Boston, Massachusetts. His most recent books are Psychiatry on the Edge (Nova Publishing) and a novel, The Director of Minor Tragedies (iUniverse).

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