Abstract
When a young resident contemplating a career in psychiatry is advised to read DSM IV-TR to encourage his interest, it is time to worry about a new anti-intellectualism or dumbing down of psychiatry. Hopefully there is more to psychiatry than lists of symptoms ticked off to generate diagnoses. What about the relationship between the categories? Do some categories take precedence over others or are all the empirically derived criteria based entities equivalent ‘disorders’? Is it worth distinguishing between what an individual ‘has’, i.e. illnesses as against what an individual ‘does’, i.e. behaviour? Are dimensions preferable to categories in describing what an individual ‘is’, i.e. personality? Is there perhaps a deep structure that underpins the discipline of Psychiatry and indeed nosology.
Nowadays few psychiatrists use the concept of phenomenological understandability to distinguish psychiatric symptoms arising from schizophrenia as against affective psychoses. Does it matter if the symptoms respond to antipsychotics regardless? Indeed much of modern psychiatric therapeutics is symptom reduction; anxiolytics if anxiety predominates, antidepressants when depression is present, mood stabilisers if there is affect disregulation and so on. ‘Polypharmacy’? Yes; but are we not just acknowledging the neurobiological substrate of symptoms? Psychiatric illnesses undoubtedly have a neurobiological substrate but whether the symptoms that emerge are a direct result of brain events or a product of the mind seems a critical issue. Of course if the position is that there is no process called mind then phenomenology which is concerned with the subjective experience of the mind is redundant and we can dispense with deep structure in contemplating human experience and concentrate on brain structure. A new brain mythology?
Sims' aptly named volume attests that there is a deeper structure to psychiatry than emerges from the pretended logical positivism of DSM III to IV-TR. Wisely Sims prefers the term descriptive psychopathology to phenomenology and does not dismay the reader by attempting to connect obscure aspects of Husserl and Heidegger with psychopathology. Yet his thinking is clearly indebted to Karl Jaspers while correctly pointing out that the philosophical roots stem from Kant rather than Husserl. Sims modestly accomplishes what Jaspers' mighty edifice fails to, that is produce a work outlining the phenomenological underpinnings of psychopathology in easily understandable form. This is arguably the best available work in English on descriptive psychopathology. Its subtitle belies its depth.
If phenomenology is the study of subjective experience then clearly diagnosis requires more and Sims pays appropriate attention to what is observable. A psychiatric diagnosis emerges from an intersection of the personal narrative (history), evaluation of the patient's subjective experience (phenomenology) and what is observed (mental state). DSM IV curiously allows diagnoses including of current major depression and indeed current mania in the absence of mental state findings. Does this account for the apparent increase in major depression? But when does an experience become a symptom, and when is a symptom indicative of illness or disorder? I am reminded of a psychiatric report claiming that the patient had post traumatic stress disorder because he had ‘unwanted memories’!
Sims provides a cogent argument to reintroduce a concept of ‘neurosis’ defined as ‘psychological reactions to acute or continuous perceived stress, expressed in emotion or behaviour ultimately inappropriate in dealing with that stress’. Such a superordinate category would obviate the need to diagnose multiple comorbid disorders in the same individual at different times and indeed at the same time. This of course requires a theoretical construct to underpin the nosology which is a heresy since DSM III.
This third edition contains discussion of adult ADHD which is unfortunately uninformative from a phenomenological or descriptive point of view and also of multiple personality disorder (MPD). On the latter Sims appears to side with those who stress the iatrogenic nature and dubious validity of the category now known as Dissociative Identity Disorder (DID). Is it characteristic of hysterical disorders that the names keep changing?
Curiously Sims only mentions PTSD in passing. A pity as this syndrome is crying out for phenomenological scrutiny. What exactly is a patient experiencing when he has ‘flashback episodes’? First appearing in DSM III ‘flashbacks’ are not defined in the glossary of this edition nor in DSM IIIR. It is described in DSM IV as ‘a recurrence of a memory, feeling, or perceptual experience from the past’ which merely begs the question. Likewise what is a person actually ‘re-experiencing’ when he is said to have ‘a sense of reliving the experience’ of the traumatic event. If the person has vivid distressing memories why not say so without resorting to words which have a certain theatrical flavour? Unfortunately we must await the fourth edition where hopefully the nature of these subjective experiences will be illuminated, assuming that PTSD as a category has not unravelled by then.