Lets Not Reify our Other Constructs Either

I am grateful to the two authors for taken the time to offer their responses, both of which speak clearly for themselves. It is tempting, but would be tedious, to list all points of agreement or disagreement. That said, I have to disagree with the claims that only little progress has been made in understanding and treating severe mental illness, and that psychiatry suffers a poverty of ideas.

Stanghellini asks that space be allowed for the place of profound experiences within psychopathology, as distinguished from psychodynamics. However, I believe it is a stretch to equate the “profound” with what is “deep,” itself an imprecise metaphor, or to suppose a casual connection between such profound change and more easily and narrowly identifiable symptoms. Indeed, this might be speculation we are more used to from psychoanalytical approaches to human phenomena, rather than from phenomenology which generally places a high value on caution in interpreting the meaning or origin of phenomena.

If I am reading him correctly, Bentall articulates a case for a symptom-based (as opposed to a diagnosis-based) approach for psychiatry, on the basis that diagnoses have unacceptably weak validity. A symptom based approach may well have practical advantages in some circumstances. Most diagnosticians, I believe, have a keen awareness of the limitations of psychiatric diagnosis. In psychiatry, for the most part, we do not have readily identifiable diseases. Diagnoses rest on identifying familiar combinations of phenomena. The limits of the consequent diagnosis require recognition, but diagnosis of some kind is still a necessary prerequisite to intervention. For example, a person’s distress that God will punish them might be an expression of depression, schizophrenia, or obsessive-compulsive disorder, or there may be no diagnosable mental disorder and the complaint understandable in terms of the person’s religious convictions. To attempt to distinguish between such situations for purposes of intervening effectively does not necessarily reify diagnosis, nor does it show disrespect to the distressed individual, nor does it imply an overestimation of the role of genes in mental disorder.

No doubt in some situations a single symptom can constitute a meaningful diagnosis. But in response to calls for a symptom-based approach to psychopathology, we could usefully reflect on how the notion of a symptom, drawn primarily from physical medicine, may itself be of limited use and is potentially misleading in psychiatry. The very notion of a symptom carries with it the implication that it is an expression of an underlying disorder. Moreover, the use of a symptom-based approach may be attended by difficulties sometimes attributed to the use of diagnoses, for example, neglect of the unique experience of the individual for the sake of those atomized experiences that can be readily quantified and classified, and of the personal context within which such symptoms maybe more or less understandable. Here rests the distinction between symptoms and phenomena that I think Stanghellini is trying to get into a clearer focus.

Again, un-understandability is only misleadingly equated with meaninglessness. When working as duty psychiatrist at the Glastonbury festival some years ago, I saw a series of several young English men with no previous psychiatric history. Each had acutely developed a delusion that they had been accused of rape or some other sexual indiscretion by the friends they were attending with. I had the impression they were generally law-abiding, well-educated, and accustomed to a role as “new men,” sensitive to the sexual and interpersonal mores of their time. Each was frantically distressed to think themselves accused of this kind of transgression. The demanding heady atmosphere of the event, combined with overindulgence in some pharmaceutical or other were the likely precipitants and I suspect all had a good recovery. That they had developed a delusions with a theme around sexual offending, I believe, reflected the times and culture they were living in. I imagine that under equivalent circumstances 120 years ago such men would have developed the delusion that they were accused of some homosexual act. The content of their delusions was wholly understandable in light of their individual personal values and...