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keys-insideThe attempt to understand the workings of the human brain and to learn exactly what goes wrong to produce mental illnesses must number among the most challenging problems scientists have ever faced. Although, for example, the DSM-5’s writing is well under way, even today its authors do not have the benefit of objective medical tests for any common mental disorder. Despite the steep challenges facing modern neurobiology, psychology, and genetics in their attempts to decode the mysteries of the brain and its ills, I argue that much can be done in constructing the DSM-5 (and also the World Health Organization’s International Classification of Diseases, 11th edition, or ICD-11) that could facilitate the transition from the shallows of descriptive psychiatry to diagnoses based on cause and mechanism.

via Diagnosing the DSM – Dana Foundation (emphasis mine)

The whole article is long but worth a read.

Until we can get brain scans that say X means you have Y we’re all going to be diagnosed for things based on our behavior and our behavior, of course, depends on a whole lot of things not the least of which is how the person observing it defines it.

Take paranoid personality disorder. According to the DSM-IV TR I can diagnose someone with paranoid personality disorder if they meet the following criteria:

A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

(1) suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her
(2) is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates
(3) is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her
(4) reads hidden demeaning or threatening meanings into benign remarks or events
(5) persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights
(6) perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack
(7) has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner

You know who gets misdiagnosed with paranoid personality disorder? Immigrants. You can look at the list above and imagine being someone newly arrived to this country, facing cultural and language barriers, dealing with prejudice and racism, learning who you can trust and who you can’t and you can see how if you showed up at a community mental health agency how you might meet #1, #2, #3, and #4.

Even as science gets better at pinpointing brain and genetic differences, how we interpret and consider those differences will change as our cultural expectations change. How we treat, for example, depression will depend on how we consider and encounter depression. Mental health professionals need to consider the diagnostic criteria, (which DSM-5 will change for many disorders); their own understanding of the client’s experience; and the client’s experience as understood by the client.

It’s clear from other kinds of physical diagnoses that how brain and genetic differences play out in our lives depends on so many other things — other physical health issues, our history, our current situation. We can look at the way the armed forces are struggling to address traumatic brain injury to see the limitations of medical diagnosis to prescribe treatment or to describe experience.

One thing is for sure, the discussion is interesting.

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