The Capacity for Adaptation
"No ideas but in things."
William Carlos Williams
1883-1963 , Rutherford , NJ
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is predicated on the criterion of impairment in functioning.
Without this criterion, there can be no “psychopathology.”
With this criterion, hundreds of “psychiatric disorders” have emerged, been reified and codified, and have likely caused harm to individuals, who may or may not have “impairment” in functioning.
“Impairment” in functioning contains a value judgment.
As physicians, we check off these values as if they were interrelated to brain function - “Yes, my patient is working and is able to maintain his or her job. Yes, my patient is in a relationship and is able to maintain his or her relationship. Yes, my patient has peers and is able to maintain an identity within a community.”
But are these the right jobs, right relationships, and right communities for the patient?
And, if the patient abdicates these aspects of his or her self, and decides to quit a job, leave a relationship, or leave a community, are these indicators of increases or decreases in functioning?
Our ability to assess impairment in functioning requires a deep understanding of the individual we are assessing and cannot be performed cross-sectionally.
A stronger criterion and a criterion that can be assessed cross-sectionally by using conversation, narrative elements, and other elements of executive functioning embedded in the interview process, is the capacity for adaptation.
Rather than asking is an individual “functioning” in extant roles in his or her life, which may or may not be healthy for the patient, we should be asking, is an individual able to “adapt” to change, to respond to adversity, to tolerate chaos?
These complex, executive functions require a coordination of limbic and cortical processes that cannot be achieved with true psychiatric diseases such as severe schizophrenia, melancholic depression, and dementia.
If we shift our paradigm from psychopathology to wellness, from the proliferation of psychiatric “conditions” to the identification of biological diseases, we may be able to exist as a field in closer alignment to the values we have sworn to uphold as physicians: “First, do no harm.”