Diagnosis Needs Existential Description Before It Can Name a Disorder

Jean-Paul Sartre begins with a paper-knife, which is a slightly fussy object for a revolution but an excellent one.

The knife has a concept before it has a body. Somebody decides what it is for, designs it, and then makes it.

Essence precedes existence. Very efficient. Very hard on paper-knives.

Human beings, Sartre says, are not manufactured that way. They appear first and define themselves afterward.

Being and Nothingness had already made the longer case at considerable length, because French philosophy had apparently decided a small ontological inconvenience required the furniture of a whole house.

Existence precedes essence.

There is no prior blueprint a person is obliged to fulfill. There is facticity, meaning body, past, social position, and the historical weather into which somebody arrives. There is no instruction manual hidden under the skin.

Kierkegaard had reached a related obstruction from the other end of heaven.

A system of existence would be possible only for God. An existing individual is still becoming, and cannot be finished in the way a system requires.

The person will not hold still for the filing cabinet.

Clinical diagnosis, meanwhile, arrives carrying a filing cabinet, a semi-structured interview, and no plausible claim to omniscience.

The DSM organizes disorders as categorical criteria sets. Symptom items, a threshold count, a duration requirement, and, for most diagnoses, clinically significant distress or impairment.

The form is deliberately auditable. A second clinician, a researcher, or an insurer can inspect the same chart, rather than relying on a persuasive story told in excellent lighting.

So the indictment writes itself.

Diagnosis is bad faith with a reimbursement code. The clinician calls someone depressive, anxious, bipolar, disordered. The label hardens. The human being disappears beneath a tidy noun.

There is something real to resist here.

Sartre’s bad faith is the self-deception that makes a person only a thing. His café waiter plays at being a waiter so intensely that the job seems to have swallowed the man.

But bad faith also goes the other way. It pretends a person has no body, history, or situation to answer to.

A category can become a cage. Refusing every category can become a trapdoor.

Diagnosis is not, by itself, the first mistake. It is a decision made under rules about what care can responsibly happen next.

At intake, the record includes onset and duration, prior episodes, family history, substance use, medical conditions, current medication, suicidality, and impairment.

The differential does not simply crown the first plausible explanation. It rules out a substance-induced presentation, then a general medical condition such as thyroid dysfunction, then bipolar disorder.

That last branch has teeth. An antidepressant can precipitate mania in unrecognized bipolar illness.

Only then does the mood presentation meet the manual, and only if impairment clears its own bar.

The diagnostic manual and the coding manual are not rival oracles either. They are adjacent bureaucracies with different jobs.

The boundary looks especially strange at grief, because grief is where a description of a life and a classification decision keep stepping on each other’s shoes.

The DSM removed its bereavement exclusion, leaving the diagnosis after a recent loss to clinical judgment when other criteria are met. Its next revision then added prolonged grief disorder, with a required duration measured in months.

The question at both moments is not whether grief is real. It is whether a fixed time-and-symptom threshold can separate ordinary suffering from a disorder that warrants a treatment pathway.

It cannot answer every question, because it was never designed to.

The first edition of the manual counted about a hundred disorders. By the fourth it counted four times as many.

That growth is partly the history of clinical refinement, and partly a reason to be suspicious of any category that begins behaving like a species discovered in a rainforest.

The suspicion has data behind it.

Field trials reported a test-retest kappa of 0.28 for major depressive disorder. Independent clinicians did not reliably converge in the way the category’s authority might encourage one to imagine.

The response from research funders was to build a parallel framework organized around neurobiological and behavioral dimensions rather than DSM categories alone.

The category remains operational. Its claim to carve nature at the joints remains disputed.

This is not a reason to turn clinical evidence into existential decor.

A manualized course of therapy for depression moves through assessment, reconceptualization, skills acquisition, consolidation, maintenance, and follow-up. It distinguishes response, a falling baseline score, from remission, a return to a non-clinical range.

Those distinctions can guide care without announcing that the person has been metaphysically solved.

Nor does the word evidence arrive wearing a crown. Modality claims are diagnosis- and severity-specific, and a treatment result is not a universal theory of a life.

Sartre’s account also needs its remainder.

His early radical freedom, in which even a prisoner chooses how to relate to imprisonment, received Marxist pressure for treating material and social constraint too lightly.

His later move toward freedom-in-situation concedes more to the world that has already happened.

The person is neither a thing nor an abstract freedom in a very expensive coat.

This is why diagnosis should not be asked to play bad faith’s part.

It may be speculation, in an individual case, that a diagnosis has eclipsed rather than clarified a person’s own situation. The label may also identify a pattern whose recognition prevents a treatment failure.

These are not symmetrical moral possibilities. They are different claims, and the chart alone cannot settle the first.

Camus, who rejected the existentialist label, calls the absurd the confrontation between a demand for meaning and a silent world.

Kierkegaard answers that exposure with a leap of faith. Camus refuses both suicide and the leap. Sartre’s atheist formula leaves the person to make meaning without a craftsman.

That division matters, because there is no single existential answer waiting to certify a clinical one.

What the two share is smaller and better than a synthesis.

Existential description asks what it is like to inhabit a freedom caught in a body, a past, and an unchosen situation. Differential diagnosis asks which account, among competing ones, makes the next act of care responsible.

One keeps the person from vanishing into the category.

The other keeps the category from becoming a beautiful reason to do nothing.