Background:
Diagnosis of psychopathology is central to the practice of clinical psychology and psychiatry. The diagnoses that you will consider in PSYC30014, The Psychopathology of Everyday Life, are intended to define the boundaries of what is considered clinically “normal” versus “abnormal”. Said differently, diagnoses seek to describe what is considered to be psychopathological or not, or put another way again, what is considered to be clinically significant, or not. In turn, diagnoses carry myriad functions. They inform prognostication and treatment planning, facilitate access to support services, influence public health policy, guide education and training, and enable communication. They additionally shape societal perceptions of and responses to, mental illness. Importantly, diagnoses also affect how people with lived experiences think and feel about their past, their current circumstances, and their future.
Prominent psychiatric classification frameworks, such as the Diagnostic and Statistical Manual of Mental Disorders(DSM – currently, DSM-5-TR) and the International Classification of Diseases(ICD) systems, serve as global standards for classifying mental health conditions. In Australia, use of the ICD system of classification and codes spans both physical and mental health practice. The ICD is used primarily for purposes of billing and resourcing, health records, and epidemiological tracking. In contrast, the DSM system is the preferred tool for use in day-to-day clinical practice given its usefulness for guiding diagnosis and treatment planning. The approach taken in the DSM to diagnosis, including diagnostic criteria, continues to evolve over time in response to progression in scientific knowledge, consensus among clinical experts as regards validity and clinical utility, and social and cultural values. The DSM model is also the dominant paradigm in Australian tertiary mental health education, and it is the framework that we will focus on in PSYC30014.
The ICD and DSM systems treat psychological problems as legitimate medical conditions. Yet, the question of whether DSM diagnoses reflect real medical conditions or are instead artefacts of prevailing social and cultural values remains a topic of significant debate in the fields of psychology and psychiatry. Some argue that psychiatric diagnoses do indeed represent genuine medical conditions, often pointing to the rapidly accumulating evidence for biological, genetic, and physiological factors that are associated with various areas of disorder. A competing perspective is that psychiatric diagnoses are not rooted in biology but are rather the result of social construction. From this perspective, what is often called ‘mental illness’ is instead shaped by historical, cultural, and political influences. From this point of view, it might be argued that a medical interpretation therefore might be less appropriate. In fact, it has been argued that the concepts of mental illness and disorders are in fact harmful myths. Here, diagnoses reflect societal norms and values about what constitutes acceptable or ‘normal’ behaviour. They serve to disempower, control, and marginalise those with lived experiences of psychological problems. The initial inclusion and subsequent removal of homosexuality as a DSM disorder is often cited as one example of how power and shifting cultural attitudes regarding acceptable behaviour have influenced the DSM.
To further complicate the debate, people with lived experiences hold a diverse range of perspectives. Some find conceptualisation of their experiences as medical conditions to be helpful and validating. Others find the biomedical approach to understanding their experiences to be stigmatising, offensive, and inadequate, and reject it enthusiastically. Many people with lived experiences alternatively report more mixed, nuanced, and changing perspectives.
The DSM-5-TR is a predominantly categorical diagnostic system. Disorders in this system are operationalised through criteria describing current signs and symptoms, duration of disturbance, and impact on functioning. Each disorder is thought to represent a unique clustering of these factors.
However, the DSM model has faced significant criticism for various reasons, and particularly its validity. A common criticism is that many DSM disorders share overlapping features. In clinical terms, we would say that many signs and symptoms (and theoretically but not represented meaningfully in the DSM, the mechanisms underlying them) occur transdiagnostically within the system. For instance, panic symptoms are not limited to panic disorder but also appear in anxiety, mood, psychotic, substance-related, trauma-related, and other disorders. Concerns regarding DSM diagnosis are also fuelled by the issue of high rates of co-occurring disorders. Indeed, it is more common than not for individuals to meet criteria for multiple DSM disorders either simultaneously or at different points in their lives. These observations raise concerns about the validity of DSM diagnoses and whether they truly reflect distinct disorders or if instead, they are simply artificial categories imposed on overlapping symptom clusters. The DSM’s categorical approach to classification is nonetheless defended as important given its utility to support treatment planning and intervention decisions. However, there is compelling recent evidence that the most broadly ecologically valid approach to conceptualising mental illness is not categorical, but dimensional. In other words, people’s lived experiences do not fall neatly into boxes of ‘having’ or ‘not having’ one or more disorders. The experiences that comprise psychopathology are often amplified everyday experiences, occurring across dimensions such as severity, frequency, functional impact, associated distress, and phenomenology. Contemporary approaches to classification and diagnosis, such as the Hierarchical Taxonomy of Psychopathology (HiTOP) model, aim to overcome the limitations of DSM framework through a framework of ordered spectrum-like continua comprising symptoms, traits, and latent dimensions such as distress, fear, tendencies to internalise or externalise problems, and more. The HiTOP aspires to provide a dimensional system that is practically useful in everyday practice; however, whether HiTOP meets this goal is a topic of debate itself.
‘Anti-psychiatry’, ‘psychiatric survivor’, ‘Mad Pride’ and similar movements emerged as a response to the prevailing biomedical approach embraced by psychiatry and clinical psychology. Prominent figures, like Thomas Szasz, argue that the biomedical ICD/DSM approach is inappropriate and harmful, and that in fact, the entire concept of ‘mental illness’, is a myth. Szasz literally wrote the book on the topic, ‘The Myth of Mental Illness’ (1961). Central to his thesis was the observation (then) that unlike physical illness, no definitive biological disease processes were conclusively demonstrated to drive experiences of mental illness. This remains largely true some 60 years later1. For Szasz and his contemporaries, psychiatric diagnoses lack biological bases and serve as a means of social and political oppression. Other anti-psychiatry figures, such as R.D. Laing, who was himself a psychiatrist, challenged the medicalisation of distress, suggesting that conditions like schizophrenia are meaningful responses to life experiences rather than brain diseases. Similarly, social theorists such as Michel Foucault and Erving Goffman discussed how psychiatry enforces societal norms and serves to marginalise and stigmatise those with psychological problems. Overall, anti-psychiatry critiques emphasise the coercive, pseudoscientific, and socially constructed aspects of historical psychiatric practice, and the harm that is caused by it.
Many contemporary ‘lived experience’ advocates and theorists argue for alternative and more suitable models that can be brought to bear on understanding and classifying mental health problems. One such example is the ‘Power, Threat, Meaning Framework’ (PTMF). The PTMF presents a radically different approach to thinking about psychopathology. It asserts that psychological problems are not medical conditions but instead reflect responses to social, cultural, and psychological factors. The PTMF emphasises the role of power, threat, and the meaning people make of their psychological distress. The model focusses on the way social inequalities and power dynamics often shape who gets diagnosed as having a mental illness and how their experiences are understood.However, like all of the other models discussed here, the PTMF has received its own significant bouts of criticism. Opponents highlight its lack of underpinning scientific rigour, oversimplified approach that lacks practical guidance for clinical practice, strong focus on social factors and lack of consideration of psychological and biological ones, and also raise questions about whether the PTMF largely repackages DSM disorders in a euphemistic and generalised way.
- While neurobiological factors such as genetics, structural abnormalities and functional problems are not directly represented in the DSM’s diagnostic criteria, a vast research literature has linked areas of DSM disorder to various neurobiological problems. To date however, none of these neurobiological problems have been found to be singularly pathognomonic for disorder. Instead, neurobiological substrates of disorder are complex. Even more complex is the interplay between biological, psychological, social, and environmental contributions to psychopathology.
Conceptualising the essay:
Humans have struggled to understand and define psychopathology throughout recorded history. As you have just read in this background brief, this remains an ongoing issue of debate and discussion. Your psychopathology essay is designed to immerse you in exploration and critical thinking about this core problem for clinical psychology.
There are many ways you can approach your response to the essay topic, “Do psychiatric diagnosesrepresent genuine medical conditions, or do they primarily reflectsocial and cultural values?”. You might choose to focus on one or more of the following perspectives below. You are equally welcome to take a different approach of your own choosing to exploring the topic. There is no ‘correct’ number of perspectives to take. An excellent essay might dig deeply into one issue or explore two in a coherent fashion. Be mindful that spreading your approach across too many perspectives is likely to limit the depth of the analysis that can be provided, and so I would encourage you to think carefully about what one or two routes you will choose. Ultimately, the choice is yours and indeed, we will be interested in the choices that you make. You can expect that our response to questions asking something like, “Can I approach the essay from X direction?” will be a response indicating to make your own judgement based on what you know about the topic and based on the marking criteria for this assessment. This should be emphasised – for all decisions about this essay, be sure to let the marking criteria (presented at the end of this brief) be your guide. One particular recommendation I will give now, however, is that you will be well served by ensuring that the direction you choose to pursue allows you to engage in evidence-based argumentation.
Here are some possible perspectives you may wish to consider:
- Biological psychiatry: the view that psychiatric disorders have biological origins, such as neurochemical imbalances or genetic predispositions, and should be treated medically.
- Dimensional vs. categorical models: dimensional models (e.g., HiTOP) argue that psychiatric disorders exist along a spectrum, while categorical models (e.g., DSM-5) define specific diagnostic categories.
- Cultural and historical context: how have diagnoses evolved over time? Consider the influence of societal changes, politics, and culture in shaping diagnostic categories and perceptions of mental illness.
- Anti-psychiatry movement: the argument that psychiatric diagnoses serve as mechanisms of social control, and that mental illness itself may be a socially constructed myth. Think about the critiques of Thomas Szasz and Michel Foucault, who argued that psychiatry often pathologizes nonconformity.
- Power and social control: Explore the idea that psychiatric diagnoses may be used to enforce social norms and reinforce power structures, particularly in marginalised or non-conformist groups.
- Medicalization of normal behaviour: Explore how ordinary human experiences, such as grief, discomfort, or anxiety, can be medicalized, turning normal emotional responses into disorders that require treatment.
- The role of the pharmaceutical industry: Consider the influence of pharmaceutical companies in shaping both public understanding and diagnostic practices, especially in areas like depression and ADHD.
- Or some other perspective that interests you!
You have considerable freedom in writing this essay. I hope that this will allow you to pursue topics and directions as regards psychopathology that are of interest to you. Again, there is no right nor wrong choice in terms of direction per se. All you need do is ensure that you are addressing the topic, the task, and the marking criteria. Below you will find more guidance on the specific task and how your essay will be assessed