Mental suffering and the DSM-5: a critical review

The definition of mental disorder included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), indicates that mental disorders are usually associated with significant distress. However, the handbook is vague with respect to whether distress is crucial to the diagnosis of mental disorders, and a conceptual framework on the precise nature of distress is lacking. As a result, it remains vague how the term 'distress' is to be taken into account in actual diagnostic situations: the DSM-5 provides no operational framework for diagnosing distress. The authors argue that the work of Georges Canguilhem, who focuses on the topic of abnormality and pathology, and Paul Ricoeur's philosophical reflections on the theme of mental suffering may provide a structure for conceptualizing and evaluating distress. Ricoeur's phenomenological model of mental suffering is discussed. Here, mental suffering can be thought of in terms of the relationship between self and other, and also in terms of the continuum made up by, what he terms, languishing and acting. Ricoeur suggests that distress is not a quantity that can be measured, but a characteristic that should be studied qualitatively in interpersonal and narrative contexts. Consequently, diagnosticians should describe and document how individuals experience subjective distress. On a practical level, this means that clinicians' ideas about patients' distress should be embedded in case formulations. A detailed evaluation of an individual's pathos-experience should be made before conclusions are drawn with regard to diagnosis.