A Perfect Storm: Health, Disorder, Culture, and the Self

I thank Jeffrey Bedrick and Somogy Varga for their insightful commentaries. They have situated my concerns over the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses’ reflective influence on self-insight in a wider net that includes the diagnosis, the patient, the illness experience, and the culture of the self. There is, of course, a tightly knit relationship between mental disorder, the self, and the larger culture. Psychiatric taxonomy is a scientific endeavor that aims to individuate accurately mental disorders; it is also an ethical undertaking that may impoverish or enrich self-insight through its influence on individuals’ self-understanding and insight into their illness.

Bedrick has two main concerns. First, he inquires whether the problem of hyponarrativity is limited to the DSMs: “Does any diagnostic system not have to abstract from the details of individual circumstances and experiences to focus on the shared aspects of the disorder to be diagnosed?” (Bedrick 2014, 157). Nor is it obvious whether “another basis for a diagnostic system would be better in this regard than a symptom-based approach” (157). I am inclined to agree. Developing a psychiatric taxonomy is a scientific project; it aims at finding the commonalities among patients’ complaints, with an aim to (i) describe the encounter with mental illness, (ii) develop possible explanations of their underlying causes, and (iii) suggest interventions that can be effective in treating all individuals suffering from the same mental disorders.

As Bedrick suggests, any diagnostic system has to abstract away the particular experiences of patients and form idealizations if its goal is to develop a shared framework for understanding and treating the individuals encountering the same condition. Following Bedrick (2014, 157), it is doubtful, for instance, whether “the disordered neural circuits that are hypothesized to be central to diagnoses by the Research Domain Criteria project would yield a richer, more individualized narrative than symptoms do.” It may also be argued that any kind of psychiatric taxonomy may yield impoverished patient insights. As I discuss in the article, however, it is not the symptom-oriented approach of the DSM alone that shapes a person’s self-insight. As I make clear, (i) the features of the DSM, (ii) the DSM culture, and (iii) the cognitive architecture of the self-work jointly to shape self-insight. What is special and interesting about the DSM’s hyponarrativity is that it might trigger a cognitive bias, known as the Barnum effect, because of which individuals identify their particular character traits, or personalities, with broad and vague categorizations or labels, even when these are not accurate portrayals of who they are (Dmitruk et al. 1973). As discussed in Section V of my article, a well-known example is our tendency to believe the accuracy of astrological signs in representing our personality (Tekin 2014a). Descriptions of mental disorders that prioritize symptoms at the expense of undermining or eliminating the subjective elements of the individual’s encounter with them have a similar influence on self-understanding. Because these descriptions are general, with no room for particular contingencies, individuals, when exposed to such information via various media of the DSM culture, might overidentify their experiences with the suggested symptoms, undermining other, more personal aspects of their lives. Thus, the symptom-based descriptions do not constitute, but rather compound, the problem.

The risk of developing impoverished self-insight via the deficiencies of the DSM’s symptom-based approach might be compensated for in two ways. First, during the clinical encounter with the patient, the psychiatrist might work on creating a more integrated narrative of her experiences, including not only the symptoms, but also the interpersonal relationships. Second, the DSM culture could be altered in a way that disseminates information about mental disorders through a more integrated framework, individuating mental illness not as a symptom cluster, but as a set of experiences connected intrinsically with the individual’s personal identity, social context, and culture. What needs to be acknowledged, perhaps, is that the DSM’s scientific goal in taxonomizing mental disorders (made explicit in the introductions of...