"I've Found Him!": Diagnostic Narrative in The DSM-IV Casebook

On admission to the psychiatric hospital, Louise sat with her hands tightly clasped in her lap and avoided looking at the doctor who interviewed her. She answered questions readily and did not appear suspicious or guarded, but her affect was shallow. She denied depressed mood, delusions, or hallucinations. However, her answers became increasingly idiosyncratic and irrelevant as the interview progressed. In response to a question about her strange cooking habits, she replied that she did not wish to discuss recent events in Russia. When discussing her decline in functioning, she said, "There's more of a take-off mechanism when you're younger." Asked about ideas of reference, she said, "I doubt it's true, but if one knows the writers involved, it could be an element that would be directed in a comical way." Her answers were interspersed with the mantra, "I'm safe. I'm safe."

—The DSM-IV Casebook

This is the final paragraph of a case description of a schizophrenic woman presented in the DSM-IV Casebook, a volume designed to aid clinicians, teachers, students, and researchers in their use of the latest edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Dividing each case into a narrative presentation and a discussion of diagnosis, the volume covers a wide range of cases, attempting to represent each diagnostic category in the DSM-IV. According to Robert L. Spitzer and the other editors of the Casebook, the discussions of the cases presented "include important diagnostic considerations, such as the rationale for making each particular diagnosis, other disorders to be considered in formulating each diagnosis, and, in some cases, recognition of diagnostic uncertainty because of inadequate information, ambiguity in the clinical features, or problems in the classification itself" (xii). The primary goal of the text, then, is to guide readers in the psychiatric professions through the differential diagnosis of mental illnesses. Where the DSM-IV itself provides catalogs of symptoms that characterize each diagnostic category, the Casebook presents narratives of individual "cases," then teaches its readers how to interpret patient speech and behavior and to transform these signs into signifiers, or, rather, symptoms. These symptoms can then be matched to the diagnoses in the DSM-IV.

Yet a close reading of the quotation above, excerpted from a case entitled "Low Life Level" in which the patient receives the diagnosis of schizophrenia, reveals that much more is at stake in this text than the identification and labeling of specific sets of symptoms. The editors claim that they "have chosen focused, edited descriptions of patients, since in standard case summaries discussions of diagnosis often get bogged down in a swamp of details not relevant to the purpose of establishing a diagnosis" (xi). In other words, each case narrative has been composed so that all its parts contribute to the process of diagnosis. Yet in Louise's case, as in the other cases of schizophrenia I will discuss here, two kinds of narrative modes seem to be in operation. In one the narrator guides the reader, as promised, through the observation of "relevant" details. This process of observation tends to be phrased in diagnostic terms, so that the reader receives instruction in interpretation even before arriving at the "discussion" part of the case study. In the other narrative mode, details that exceed the process of diagnosis are presented. This mode creates a fractured storyworld that in many places blots out the clinical scene. One sign of this mode is the fact that elements appear in the case presentation that remain unexplained, in fact unaddressed, in the case discussion that follows it. These elements are at times initiated by the narrator of the case and at times emerge through the partially presented words and actions of the patient. Traces of what we might call "shadow narratives" appear intermittently, and in the chronology of the case study they are virtually always superseded by...