The four domains of mental illness (FDMI): An alternative to the DSM-5
René J. Muller
Between 1994 and 2004, I evaluated over three thousand psychiatric patients in the emergency room at three hospitals in Baltimore (Muller 2003). About halfway through this decade, I began to realize that at least half of my patients who had previous psychiatric treatment carried a wrong diagnosis. Patient after patient, describing the crisis that brought them to the ER, came clean with me about what was going on in their lives. Many actually knew they did not have the mental illness they had been diagnosed with and didn’t need the medication they had been prescribed, and, in many cases, were still taking. Not only were these patients being treated for a mental illness they didn’t have, their real problem was going unaddressed.
Eventually, I came to see that the method fostered by the American Psychiatric Association for diagnosing mental illness—the Diagnostic and Statistical Manual of Mental Disorders, at that time the DSM-IV (1994)—was a virtual invitation for clinicians to get a diagnosis wrong. In 2008 I published Doing Psychiatry Wrong: A Critical and Prescriptive Look at a Faltering Profession (Muller 2008), where I spelled out the damage that I saw done to patients who were misdiagnosed. Though many clinicians had hoped that the DSM-5, which derives from the same paradigm as the third and fourth editions, would be a better guide to making valid psychiatric diagnoses, it became clear to me that this was not the case (Muller 2013).
The official rollout of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) at the May 2013 meeting of the American Psychiatric Association included the acknowledgment by the Task Force that their primary goal—producing a guide that would permit the diagnosis of mental illnesses to be based on a detectable biological cause—had not been met. Days before the official unveiling of the DSM-5, a number of psychiatrists who were closely associated with the project scrambled to do some preemptory damage control, mostly by lowering expectations for what was to come.
Michael B. First, professor of psychiatry at Columbia University, acknowledged on National Public Radio that there was still no empirical method to confirm or rule out any mental illness: “We were hoping and imagining that research would advance at a pace that laboratory tests would have come out. And here we are 20 years later and we still unfortunately rely primarily on symptoms to make our diagnoses” (Hamilton 2013).
Speaking to the New York Times, Thomas R. Insel, director of the National Institutes of Mental Health, insisted that this failure had not been for lack of effort: “We’ve tried. You know we’ve actually looked—using brain imaging, using various endocrine tests, looking at a range of other kinds of biomarkers. So far that has been found wanting” (Belluck and Carey 2013).
In the same Times article, David J. Kupfer, chairman of the DSM-5 Task Force, admitted “a failure of our neuroscience and biology to give us the level of diagnostic criteria, a level of sensitivity and specificity that we would be able to introduce into the diagnostic manual.” Kupfer, Insel, and First agree that the new paradigm envisioned for psychiatry—the reason the new edition was undertaken—remains elusive.
Nonetheless, four months after publication, following many lukewarm and negative reviews, the DSM-5 had sold 382,000 copies and brought in $33.7 million. Over the previous ten years, the fifth edition had cost the APA about $22 million to produce.
Largely eschewing the DSM’s paradigm, which rests on the notion that all mental illnesses are brain diseases, the department of psychiatry at the Johns Hopkins University School of Medicine continues to follow Adolf Meyer’s psychobiological approach to diagnosing and treating mental illness that was instituted by Meyer while he was chief of psychiatry there from 1910 to 1941. In 2013 Johns Hopkins celebrated the centennial of the Henry Phipps Clinic, created by Meyer to foster his vision for mental health.
In Meyer’s psychobiology—the psychological study of the person in the context of biology—every facet of life is simultaneously and inseparably both psychological and biological. The Johns Hopkins (and later Harvard) psychiatrist Leon Eisenberg famously remarked that asking how much of what people do is psychological and how much is biological is as unproductive as asking how much of the area of a rectangle derives from its width and how much from its height (Eisenberg 1995). To psychobiologists, the terms psychological and biological do not signify a separation of mind and brain, but specify two polarities of a single unit, the person. To existentialists, this entity is the self as active agent, a designation that Meyer would have surely endorsed.
Meyer insisted that most mental illnesses emerge out of lives dynamically rather than impinge on them biologically. He did not believe that the majority of these illnesses were brain diseases, or were passed along genetically. In his psychobiological synthesis, Meyer saw the mind as the organ of personality. He had already grasped the modern notion of epigenesis—that a person’s experience in the world, with others, shapes a life, simultaneously altering brain structure and function. This “biological” alteration may then influence “psychological” development, opening a “two-way street” that remains open through the life course. In this psychobiological view of self-creation, the “man-made”—and ultimately invalid—distinction between psychology and biology disappears.
In 1998 Paul R. McHugh and Phillip R. Slavney, professors of psychiatry at Johns Hopkins, published the second edition of their Meyerian treatise The Perspectives of Psychiatry (McHugh and Slavney 1998). Their intention was to systematize Meyer’s often vague, unstructured notions about mental illness so as to make his psychobiological approach more accessible to clinicians and clinical researchers. They began by distinguishing four different types of psychopathology, based on etiology and the meaning of symptoms, distinctions that were purposely omitted in the DSM-III (1980), DSM-IV (1994), and DSM-5 (2013).
If not all mental illnesses are brain diseases, the question then becomes how do these illnesses come to be? Who is at risk, and why? The Johns Hopkins perspectives offer four different directions from which to view a patient’s pathological predicament based on etiology, as far as this can be discerned given our present state of knowledge. Clinicians are prompted to look down four different axes, so to speak, to see how a person’s mental life has been pathologically altered.
Since 2011, in consultation with Paul McHugh, now university distinguished professor of psychiatry at Johns Hopkins, I have been working on a guide for classifying and diagnosing mental illness—The Four Domains of Mental Illness (FDMI)—that is rooted in The Perspectives of Psychiatry and Meyer’s psychobiology. The FDMI does away with the DSM’s checklists of mostly behavioral symptoms, which were originally justified by the promise of finding a biological cause for every mental illness, in favor of identifying the altered emotions, thoughts, and acts that constitute the phenomenon of each illness. The heart of this process is establishing, as far as possible, the psychobiological origin of the phenomenon, along with its meaning. Meyer implicitly took this phenomenological approach to diagnosis, as did McHugh and Slavney in The Perspectives of Psychiatry.
The DSM-III, DSM-IV, and DSM-5 were modeled on the idea of Emil Kraepelin (1856–1926) that mental illnesses are categorical disease entities, syndromes comprised of symptoms that demarcate one illness from another. (Hence the pie charts and Venn diagrams that show the “overlap” of symptoms and the “comorbidity” for different illnesses.) In contrast, the perspectives and the FDMI are based on a dimensional model of mental illness, which sees thought, emotion, and behavior as falling along a continuum from normal to aberrant, where pathology is defined as a phenomenon that occurs beyond a certain point in that continuum.
Each of the four perspectives identified by McHugh and Slavney implies a corresponding pathological domain, a lived space created and inhabited by someone with a mental illness. Meyer, who was an existentialist in all but name, would have surely agreed that a psychiatric diagnosis should access and assess a patient’s lived experience—colloquially, where the patient lives. (Domain derives from the Latin territory.) The FDMI also allows the clinician who is evaluating a patient for an abnormality in one domain to simultaneously assess deviances in the other domains, which may be contributing to the patient’s altered mental life.
Viewing mental illness from four perspectives and defining the corresponding domains—a domain is a part of the patient’s disturbed world that a perspective invites us to enter—permits a “first cut” to be made in parsing the varieties of psychopathological phenomena (Table 14.1). This four-part division is a considerable refinement over the divisions made by Meyer, and in the DSM-I (1952), which is largely based on Meyer’s psychobiology. It is also a different kind of sorting. Each perspective in The Perspectives of Psychiatry, and each domain in the FDMI, derives from a psychobiological deviation from normalcy that can be distinguished from deviations in the other three domains. Not infrequently, deviations in multiple domains contribute to a person’s illness.
Because, for the FDMI, it seemed sensible to consider the most prevalent mental illnesses first, the order of the domains that derive from the first and fourth perspectives were interchanged. This change also permits the discussion of mental illness to begin with anxiety, rather than with brain diseases as is the case in The Perspectives of Psychiatry—a desirable strategy since pathological reactions to anxiety are generally seen as the root of all psychogenic illness. Chisolm and Lyketsos had previously made this switch in their book Systematic Psychiatric Evaluation: A Step-by-Step Guide to Applying “The Perspectives of Psychiatry” (2012).
The designation disease (first perspective, fourth domain) is conserved in the FDMI. However, we believe that parsing the other three domains as dimension, behavior, and story, as is done in The Perspectives, would not adequately differentiate or characterize the illnesses in these domains. Consider: first, whatever can be called human, whether normal or aberrant, is eventually manifested as behavior; second, all behavior is dimensional, which is to say that all behavior falls along a continuum from normal to aberrant; and third, all behavior can be parsed as a series of stories that ultimately allow us to see the shape of our lives. In the FDMI, what constitutes the essence of the dimension, behavior, and story perspectives for each of these domains is recast as brief descriptions of three different, though sometimes interdependent, types of defensive psychobiological reaction—Meyer’s term, signifying both the active participation of the person undergoing the reaction and the pathological change incurred.
Meyerian reactions of the first domain originate in maladaptive reactions to life’s challenges, stresses, losses, and failures.
The most common illnesses deriving from these reactions are the multiple clinical expressions of anxiety; panic (the body’s manifestation of severe anxiety); demoralization and depression; pathological anger; dissociation; psychobiogenic psychosis (delusions, hallucinations, paranoia); and severe obsession–compulsion, which exceeds anything that could follow from a second-domain obsessive–compulsive style, and can include psychosis.
While all mental illnesses have biological correlates, brain pathology is not the primary cause of first domain illnesses, though it is generally agreed that some people are more psychobiologically vulnerable to developing these illnesses. (Biological correlates of many mental illnesses have been identified. Reduced brain glucose metabolism revealed in PET scans of depressed persons is widely, and wrongly, cited as proof that depression is a brain disease.)
Second domain reactions come about in the context of aberrant personality development and temperament. Biological factors contribute, but are not primary causes.
Not everyone receives the minimum parental and social affirmation required to develop a degree of selfhood necessary to withstand the challenges of life and succeed as a person. What we are calling pathological personality styles (paranoid, borderline, narcissistic, histrionic, schizoid, antisocial, and obsessive–compulsive) are thought to take root in the developmental—really, psychobiological—deficit incurred in these situations. Many people with pathological personality styles have trouble controlling their expansive and destructive impulses, leading them to have highly conflicted and painful lives, while often causing hardship for those they interact with (Shapiro 1965). Those with pathology in the second domain are more likely to succumb to defensive reactions of the first and third domains because of the brittleness of self associated with these deficits. Psychosomatic illness also falls in the second domain.
Third domain reactions are willed, self-gratifying, and ultimately self-destructive acts that exceed the limit of what most people consider safe, sensible, and authentic behavior.
These reactions include alcohol abuse; drug abuse; pathological gambling; sexual paraphilia; anorexia; bulimia; kleptomania; pyromania; trichotillomania; and, paradoxically, self-injury (cutting, burning). In most third domain reactions, people deceive themselves as they deny the price they and others are paying for their actions. Many third domain behaviors damage the body biologically, and this fact is often used to buttress the false argument that these reactions, especially alcohol and drug dependence, and eating disorders, are autonomous brain diseases.
Citing Meyer’s distinction, mental disturbances of the fourth domain are those that “impinge” autonomously on a life as if from the outside rather than “emerge” dynamically from life choices as happens with reactions of the first three domains.
This kind of alteration in mental state can be due to a generally correctable physiological change known as delirium—a clouding of consciousness that accompanies metabolic and electrolyte imbalances, drug toxicity, and some medical conditions (Slavney 1998).
Autism is a condition of arrested psychobiological development, making this disorder a candidate for the second domain. But deviant biology seems to be more of a factor here than in other second domain illnesses, impinging on rather than emerging from the lives of its young victims, to cite Meyer’s distinction. Until there is evidence to the contrary, autism is probably best assigned to the fourth domain—though when doing clinical work with patients, what we have learned about second domain pathology should influence our approach (Levin 2014).
Neurodegenerative, dementing diseases such as tertiary syphilis and Alzheimer’s irreversibly damage the brain’s neural substrate causing numerous psychiatric symptoms, including delusions and hallucinations.
The primary psychiatric illnesses of the fourth domain, schizophrenia and manic depression, are putative brain diseases: putative because, unlike tertiary syphilis or Alzheimer’s, no brain abnormality has yet been identified that explains either illness, even after 150 years of intense research. Some psychotic experiences diagnosed as schizophrenia and some disturbances of mood diagnosed as manic depression are most likely autonomous brain diseases that, in Meyer’s words, biologically impinge on a person. But many of these alterations in emotion, cognition, and behavior are first domain or second domain dynamic reactions accompanied by psychobiologically altered brain substrates.
The DSM-5, which intentionally disregards the etiology and meaning of psychiatric symptoms (beyond ruling out a medical condition as the cause), does not offer clinicians sufficient guidance to make the kind of diagnostic distinctions that are allowed by the FDMI. Instead, following the medical model for diagnosis, the DSM designates sets of mostly behavioral symptoms as signifying single mental illnesses, and takes all mental illnesses, including all psychotic illnesses, to be brain diseases. The FDMI and the DSM originate in, and are defined by, two essentially incompatible paradigms.
During several decades of clinical work, I saw many patients who had been previously misdiagnosed and wrongly treated using the DSM’s approach. Some patients had psychotic symptoms and were incorrectly diagnosed with schizophrenia. Especially disturbing were the overzealous attempts by clinicians to identify and treat, usually with “antipsychotic” drugs, what they called “early schizophrenia” in children and adolescents. Again, these clinicians followed the medical model: diseases are best diagnosed early and treated early. There are many reasons why young people, or, for that matter, people of any age, have delusions and hallucinations. Most do not have schizophrenia.
Just how different the FDMI is from the DSM-5 can be appreciated when we recall that schizophrenia, alcoholism, and PTSD are all considered to be brain diseases in the DSM, while in FDMI schizophrenia falls in the fourth domain (putative altered brain substrate leading to a disease), alcoholism in the third domain (willed choice of self-destructive behavior), and PTSD in the first domain (failing to meet life’s challenges and recover from setbacks) (McHugh 2012). It should be obvious that patients who are diagnosed with the guidance of the FDMI would think differently about the predicament they find themselves in than if they were diagnosed with the DSM-5. And, of course, they would receive a different kind of treatment.
The two life-stories that follow should help to hone the distinction made in the FDMI between first and fourth domain psychotic experiences—with allowances, of course, for the ambiguity that is inevitable when phenomena of only partly understood etiology and meaning are parsed and compared. The point here is not simply to hold up these individuals as exemplars of one mental illness or another but, using these examples, to designate the phenomenon which constitutes that illness. To do this requires going beyond the specifics of any case, no matter how compelling, to universal essences. Though the life-stories of Mrs. K and John Nash, which led to diagnoses of a first domain paranoid reaction and fourth domain schizophrenia respectively, are just two of the pathological phenomena elucidated in the FDMI (Table 14.1), it is hoped that the richness of these stories of altered mental life will give the reader a sense of what it means to uncover the truth about someone who is mentally ill by identifying the phenomenon, or phenomena, behind the illness. This chapter is a synopsis of a text, in progress, that aims to characterize the phenomena of all the mental illnesses represented in Table 14.1.
Table 14.1 The Four Domains of Mental Illness
* The entries for delirium and neurodegenerative diseases in the fourth domain were adapted from Slavney, P. R. (1998). Psychiatric Dimensions of Medical Practice. Baltimore: The Johns Hopkins University Press.
Mrs. K, who is 95, lives alone in a ranch-style house on half an acre of land in a rural suburb. On most days during the spring, summer, and fall when the weather is good, she works outdoors in the garden. During the fall of her 95th year, she raked 40 bags of leaves. During the winter, when the snow is six inches or less, Mrs. K shovels the driveway out to the road. After heavier accumulations, she calls in someone with a plow. She never complains about having to cope with the long, cold winters.
Mrs. K pays her own bills and never overdraws her checking account. She prefers to spend most of her time alone and encourages only occasional short visits from family members. She has no friends and wants none, even though neighbors occasionally make overtures to her. She keeps up with the outside world by watching the news on cable TV. In 1986 Mrs. K’s husband died suddenly from heart failure. She has never shown any sign of mourning and, in fact, appeared to be rejuvenated by her husband’s death. Though Mrs. K values life in her advancing years and takes good care of herself, she has made it clear that she is not afraid to die.
Mrs. K has a good quality of life and can still do many of the things that were always important to her. Her sense of the world is largely intact. She appears thin and frail, but for a nonagenarian her health is good. Her close vision has deteriorated because of macular degeneration, and she can no longer sew, but beyond six feet she sees well. She takes 81 mg of aspirin every other day, and receives monthly subcutaneous injections of vitamin B12 and folic acid. Mrs. K has had occasional chest pains since her mid-eighties, which her doctor attributes to angina. Sometime after that she was found to have atrial fibrillation. Her only prescription medications are Cardizem and Plavix.
Mrs. K has a son and a daughter, both in their sixties. The daughter and her four adult children live nearby. The son lives in a distant city. The daughter, who is divorced, does Mrs. K’s grocery shopping and drives her to doctors’ appointments.
Mrs. K’s mental life is intact, except for one glitch: she claims to believe that her grandchildren come in the middle of the night, or when she is away during the day, to steal her possessions and that her daughter knows and approves of this. The “stolen” items include sheets, towels, pots and pans, milk, and orange juice. According to Mrs. K, her sterling silver and antiques are being sold and replaced with cheaper items by her grandchildren so they can pocket the difference. These accusations have been made time and again, over a period of many years. Mrs. K also claims that her phone is being tapped. She puts all the blame for this intrusion on her grandchildren and does not feel that either the phone company or the government is involved. According to Mrs. K, the grandchildren listen in on her phone calls because they want to know when she is going to sell her house and when they will get their inheritance.
Mrs. K alleges that her grandchildren steal from her and covet her money because things are not going well for them. Being reminded that three of the grandchildren have good jobs and that the fourth has a husband who makes a respectable living does not sway Mrs. K from this belief. She has been able to convince herself that her grandchildren need the money they steal from her to survive, and that she is their savior. Mrs. K’s apparent hatred of her family, manifested in many ways over many years, seems to be transformed through this self-deception into an act of their betrayal. The ultimate reason for this woman’s hatred is opaque, but there has always been something about her family being successful and happy that has threatened her and tweaked her envy.
Mrs. K clearly meets criteria for what the DSM-5 designates as delusional disorder, persecutory type. Though she has often directed outbursts of anger tinged with paranoia at family members, she has never shown any indication of being clinically depressed, or of having had a sustained period of low mood. No case can be made for psychotic depression or for schizophrenia. Mrs. K has never been manic or hypomanic, or ever abused alcohol or any other drug. Neither she nor any of her blood relatives have been diagnosed with or treated for a mental illness.
The FDMI places Mrs. K’s pathology in the first domain, and, following Meyer, names her behavior a paranoid psychotic reaction.
John Nash is considered to be one of the great mathematical minds of the twentieth century. A Princeton Ph.D. at age 21, he is best known for developing the mathematics of game theory that was later used to plan military and economic strategy.
During the 1950s, while he was still doing what was considered brilliant work, his thinking, feeling, and behavior became unaccountably bizarre, and he was eventually diagnosed with paranoid schizophrenia. Nash angrily resigned his positions at Princeton and M.I.T., making bitter accusations against his stunned colleagues. His wife was not spared from his paranoid rage. After standing by him for many years, she divorced him (they later remarried). He floundered badly, could not do any sustained mathematical work, or teach, and lost the ability to function socially.
Nash had paranoid and grandiose delusions and auditory hallucinations. He came to believe that extraterrestrials were sending him messages and that the course of his life was being determined by certain sequences and patterns of numbers. He showed a partial response to Thorazine and Stelazine, but refused to take antipsychotic drugs after 1970. In the mid-1980s, after struggling for three decades with a serious mental illness that required many hospitalizations, Nash mysteriously got over the worst of this illness and reclaimed a part of his life and his career. He was awarded the Nobel Prize in economics in 1994 for work he had done before he became ill.
In 1998 Sylvia Nasar published a widely praised biography of Nash, A Beautiful Mind (Nasar 1998). She carefully parsed every phase of Nash’s life, showcasing his brilliance, nobility, and tragedy. It is clear from Nasar’s book that, during the prodromal phase of his illness, Nash was anxious and overwhelmed by the pressures of work and marriage, as well as by the conflict he seems to have felt about his homoerotic attachments.
Nash had always been considered aloof and eccentric. These personality traits are not unusual in persons who breathe the rarefied air of mathematics and theoretical physics where the abstract is prized over the concrete and the hard edges of everyday reality can be avoided as a matter of course. Leonard Mlodinow, a physicist, acknowledged that “one of the advantages of theoretical physics is that you can wander in different realities, and yet you’re not considered mentally ill” (Mlodinow 2012). Under pressure, Nash may have found it relatively easy to blur the boundary between a world that was becoming increasingly difficult for him and a world of fantasy that was more palatable.
In the spring of 2002, the Public Broadcasting Service (PBS) aired a TV program on Nash titled A Brilliant Madness. Nash provided some insightful sound bytes, including this one: “To some extent sanity is a form of conformity. People are always selling the idea that people with mental illness are suffering. I think madness can be an escape. If things are not so good, you maybe want to imagine something better. In madness, I thought I was the most important person in the world” (Kennedy 2002). Nash seems to be saying that he rejected the rational world after it became too painful for him to live there. The delusional ideas he developed seemed real, he said, because they came to him in the same way that his mathematical ideas came to him.
Nash claims that he partially willed his illness into being and then willed his recovery as well. Of the voices that directed his life while he was seriously ill he said, “I began rejecting them and deciding not to listen” (James 2002). His language is direct and strong here, and his words are those of someone who feels that he is in control—he rejected, he decided. In 1996 Nash recalled, “I emerged from irrational thinking ultimately, without medicine other than the natural hormonal changes of aging” (Nasar 1998: 353). To hear John Nash tell it, what the existentialists call the self as active agent appears to have been calling the shots all along.
What may ultimately distinguish the phenomenon of a first domain psychotic reaction from the phenomenon of schizophrenia, a putative brain disease of the fourth domain, is the degree of psychobiological disintegration—the “hit” taken by the organism—that occurs when a constitutionally vulnerable person is psychically traumatized to the point of opting out of reality, to follow one escape route or another to an “inner” world. Meyer believed that a dynamically driven psychotic experience can alter brain structure and function. “Mind,” he said, “like every other function, can demoralize and undermine itself and its organ,” the brain (Meyer 1906). Seen in this way, psychoses of the first and fourth domains are psychobiological phenomena of different pathological power within a continuum of psychotic experience.
Mrs. K limited her paranoid psychotic reaction to her family. Whatever the origin and nature of the anxiety that spawned her pathological thinking and behavior, it did not require her to be any crazier than that. In his schizophrenic reaction, as Meyer would have called it, John Nash needed to psychotically transform his entire world and everyone in it. At its peak, his psychic terror, an emotion that was an order of magnitude more intense and crippling than any anxiety Mrs. K may have felt, demanded an escape from reality itself. If we believe Meyer, Nash’s greater psychological transformation caused a greater correlative biological upset as well, putting his illness well into the fourth domain, and leaving us to wonder just what kind of reversible “brain disease” Nash actually had!
Which is why, when speaking of schizophrenia, we say “putative brain disease” to distinguish this illness from fourth domain neurological diseases such as tertiary syphilis and Alzheimer’s that also produce psychotic symptoms, but have known organic causes. Again, following Meyer, we can picture a schizophrenic reaction epigenetically altering a brain’s structure and function, sometimes in a way that is reversible, as Nash’s illness was at least partly reversible. Schizophrenia has long been recognized as a heterogeneous illness. There are undoubtedly other schizophrenias that are more biological than Nash’s, more genetic, more disease-like.
Our ultimate goal as clinicians is to get our patients right, and persuade them to exchange a life that does not work well for them for one that works better (Frank and Frank 1991). To do that, we must grasp the essence of what it means to be a person, in health and in sickness. The DSM-III, DSM-IV, and DSM-5 ultimately fail because these systems endorse a way of diagnosing mental illness that denies the radical essence of every person’s life: freedom.
To deny freedom is to deny responsibility. Grounded in these denials, the DSM is a veritable invitation for clinicians to get a diagnosis wrong. Purposely ignoring etiology, and taking symptoms at face value, the DSM makes no provision for holding patients (or anyone else) accountable for a mental illness they develop.
What most differentiates the FDMI and the DSM is the notion that, to a considerable degree, the person we become emerges from the sum of the choices we make in the process of exercising our freedom. Originating in what is surely one of the great philosophical insights of the twentieth century, Jean-Paul Sartre declared that “we are condemned to be free” (Sartre 2007: 29). We have no choice in the matter, only in how we use or misuse our freedom. Being condemned to freedom is the ur-paradox of human existence!
Even while we are denying our freedom, which we all do at times, especially under pressure and when things go badly, we are using that freedom to construct this denial: refusing to choose is a choice. In the Meyerian and existential formulations of psychopathology, most mental illnesses are thought to originate in a person’s self-deceiving misuse of freedom. In the FDMI, freedom and its misuse play out across all four domains, though in different ways in each domain, and to different degrees.
While acknowledging the limits of what we know about how and why people become mentally ill, the FDMI offers clinicians an approach to parsing the varieties of mental illness that affords both freedom and biology their due, so that patients can receive their due. To do justice to the growing number of patients who are seeking our help, the mental health profession must create a valid paradigm based on a valid anthropology—the notion of what it means to be a human being—and jettison the current paradigm that falsely informs the DSM-5 (Muller 2013).
Truth stipulates that an entity is represented as it is before preconceptions and bias transform it into something else. Ultimately, we need to think about the world in such a way that our own “bias”—no one is without a point of view—tends toward a perspective that can be considered valid because it does not distort what is there.
William James (1842–1910) was an American philosopher and psychologist whose New-World existential thinking—known as pragmatism—significantly influenced Meyer, and united him in spirit with the European existentialists. James and Meyer shared the existentialists’ view that the truth about others could be intuitively known, a notion that the logical positivists vigorously deny. This denial is a major component of the anthropology that underlies the DSM-III, DSM-IV, and DSM-5, and allows the etiology and meaning of symptoms to be ignored. To James, Meyer, and the existentialists, such a view of what a person is would preclude a valid understanding of the person’s behavior, normal or otherwise.
In his superb rendering of James’s life and work, A Stroll with William James, Jacques Barzun begins the discussion of pragmatism by citing the need for what he calls a “test of truth.” How, he asks, can we know anything substantial about a life that is flux at its core?
If Experience as natively given in consciousness is fleeting, variable, helter-skelter, and if we have the power to work upon it, by attention, by making concepts, by combining images, then we need a way of making sure that the account we give of any experience, the bearing of any connections we discover, is solid, reliable, permanent because [it is] rooted in the nature of things (Barzun 1983: 83).
A stick is placed in a transparent container filled with water, one long enough to extend several inches above the surface of the water. Barzun asks us to consider the conundrum of what is observed. At the water line,
we see certain lines and colors that makes us think [the stick is] broken—we know from past experience that that is how a broken stick looks. But if we have any doubt, we slide our hand along the stick in the water and feel no break: the idea “broken stick” is not true; it disagrees with a subsequent, relevant experience. The pragmatic test is repeated when we pull the stick out of the water, see it whole and lean on it—not broken (Barzun 1983: 86).
Ever the concrete thinker, James locates truth close to the ground: “Truth is simply a collective name for verification processes, just as health, wealth, strength, etc. are names for other processes connected with life. Truth is made, just as health, wealth, and strength are made, in the course of experience” (James 1907: 218).
Pragmatically speaking, truth is what works, and what makes sense in the context of everything we know about the world. Clearly, James’s “truth” aphorism does not cover all we encounter. James, like Meyer, realized that theories are not absolute transcripts of reality. “Their great use is to summarize old facts and to lead to new ones. They are only a man-made language, a conceptual shorthand, in which we write our reports of nature” (James 1907: 212–13, 57).
Let us apply James’s concept of truth to the claims made by the creators of the third, fourth, and fifth editions of the DSM that the mostly behavioral criteria in these texts can be used to diagnose mental illnesses—in spite of their acknowledgment that what was done to increase reliability compromised validity in the process (Bernstein 2011). This trade-off ignores the fact that even if reliability were improved—but how could it be with all the diagnostic “noise” generated by ignoring the etiology and meaning of symptoms?—the sacrifice of validity would render this “reliability” worthless. The DSM-5 fails the pragmatists’ test of validity: it does not work. It leads, ineluctably, to many wrong diagnoses. It cannot be fixed because it is not broken—it is just wrong. As a result, countless patients have been compromised, and the results of a good deal of psychiatric research based on diagnoses made using the DSM’s last three editions fall wide of the mark.
Every beginning course in natural science belabors the distinction between validity and reliability, and the importance of this distinction in doing research and interpreting data. But the creators and users of the third, fourth, and fifth editions of the DSM appear to have forgotten their early science training when they created the implicit subtext that as long as clinicians agree, to some extent anyway, on a wrong diagnosis, their agreement trumps the need to get a correct diagnosis. It is hard to imagine what standard of truth and validity is met here. Had Adolf Meyer lived to see the DSM-5, he undoubtedly would have felt that this approach to classifying and diagnosing mental illness lacked “commonsense” (Lief 1948)—the signature of his psychobiological approach—and that the DSM-5 was invalid.
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