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Thank you, Awais, for this elegant take-down of psychiatry's most vociferous and least-informed critics (there are, of course, eloquent and well-informed critics who do not seek to trash the entire clinical enterprise of psychiatry and psychiatric diagnosis).

The etymology of the term "diagnosis" is critical to understanding what psychiatrists actually do, as contrasted with what anti-psychiatry critics mistakenly believe we do. The term means, literally, "knowing the difference between" (dia-across, between; gnosis, knowledge or knowing). The psychiatric diagnostician's goal, upon first meeting the patient (from the Latin “patiens,” from “patior,” to suffer or bear) is to determine the difference between certain broad types of human experience: for example, an existential crisis vs. a psychotic break; or normal confusion brought on by stress vs. an incipient dementia.

Contrary to the puerile cliche that the DSM is "Psychiatry's Bible," we make use of the patient's symptoms and signs in a holistic, gestalt manner to arrive, initially, at a general type of human experience. As you suggest, this is often done clinically through "prototype matching". And as you say, "Prototypes are characterized by vague and fuzzy boundaries that overlap with neighboring prototypes." And there is nothing wrong or unscientific about this "fuzziness"! As Ludwig Wittgenstein once noted, a fuzzy beam of light is just as real as a sharply focused one [ Wittgenstein L: The Blue and Brown Books, New York, Harper Torchbooks; 1965].

We then try as best we can to refine our initial dia-gnosis [knowing the difference between] by means of laboratory testing (to rule out, e.g., an endocrinopathy); imaging studies (to rule out, e.g, a brain tumor); and in some cases, neuropsychological testing (to ascertain, e.g., certain personality traits). Often, we consult family members or school reports to confirm initial diagnostic impressions.

The DSM diagnostic categories, we clearly recognize, are only rough-and-ready guides to dia-gnosis, and not the alpha and omega of understanding [cf. verstehen] the patient's situation or problems. Often, we do not arrive at a "specific and certain" disease entity as the driving factor in the patient's presenting illness (if illness it be). This is also true in much of general and family practice. As family physician Kirsti Malterud, MD, PhD has noted, it is rare, in family practice, that the physician can link specific observable signs to a specific localized lesion or pathological process. On the contrary,

“The professional norm that objective signs are supposed to confirm subjective symptoms and thereby reveal monocausal disease processes falls apart in the sea of medical complexities encountered by the family physician.”

Nevertheless, Dr. Malterud notes, "...the solution of the patient’s problem can often be achieved despite the impossibility of reaching an established medical diagnosis." [Malterud K: Diagnosis-A tool for rational action? A critical view from family medicine. Atrium, Winter, 2013, pp. 26-35.]

Finally, Awais, you note that "...Many clinicians also complement the diagnosis

with a narrative diagnostic formulation that summarizes their conceptualization of predisposing,

precipitating, and perpetuating factors." I am not sure how many psychiatrists actually do this, in addition to merely proffering a DSM diagnosis--but in fact, the DSM-5 Manual itself requires such a case formulation, without which a legitimate diagnosis cannot be made. As the Manual clearly states on p. 19, "...it is not sufficient to simply check off the symptoms in the diagnostic criteria to make a mental disorder diagnosis."

And though it hardly seems necessary to say it, clinical care without a meticulous process of diagnosis is like the empty shell of a building without its core.


Ronald W. Pies, MD

For further reading:

1. https://www.psychiatrictimes.com/view/science-psychiatry-and-family-practice-positivism-vs-pluralism

2. https://peh-med.biomedcentral.com/articles/10.1186/1747-5341-7-9

3. https://awaisaftab.blogspot.com/2020/06/an-exchange-with-ruffalo-pies-more-on.html

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