This chapter examines philosophical issues surrounding the classification of mental disorders by the Diagnostic and Statistical Manual of Mental Disorders (DSM). In particular, the chapter focuses on issues concerning the relative merits of descriptive versus theoretical approaches to psychiatric classification and whether the DSM should classify natural kinds. These issues are presented with reference to the history of the DSM, which has been published regularly by the American Psychiatric Association since 1952 and is currently in its fifth edition. While the (...) first two editions of the DSM adopted a theoretical (psychoanalytic) and etiological approach to classification, subsequent editions of the DSM have adopted an atheoretical and purely descriptive (“neo-Kraepelinian”) approach. It is argued that largest problem with the DSM at present—viz., its failure to provide valid diagnostic categories—is directly related to the purely descriptive methodology championed by the DSM since the third edition of the DSM. In light of this problem, the chapter discusses the prospects of a theoretical and causal approach to psychiatric classification and critically examines the assumption that the DSM should classify natural kinds. (shrink)

A common theme in the contemporary medical model of psychiatry is that pathophysiological processes are centrally involved in the explanation, evaluation, and treatment of mental illnesses. Implied in this perspective is that clinical descriptors of these pathophysiological processes are sufficient to distinguish underlying etiologies. Psychiatric classification requires differentiation between what counts as normality (i.e.- order), and what counts as abnormality (i.e.- disorder). The distinction(s) between normality and pathology entail assumptions that are often deeply presupposed, manifesting themselves in statements about what (...) mental disorders are. (shrink)

This paper explores the differences between bringing about self-change by way of antidepressants versus psychotherapy from an ethical point of view, taking its starting point in the concept of authenticity. Given that the new antidepressants (SSRIs) are able not only to cure psychiatric disorders but also to bring about changes in the basic temperament structure of the person—changes in self-feeling—does it matter if one brings about such changes of the self by way of antidepressants or by way of psychotherapy? Are (...) antidepressants a less good alternative than psychotherapy because antidepressants are in some way less authentic than psychotherapy? And, if so, what does this mean exactly? In this paper I try to show that the self-change brought about by way of antidepressants challenges basic assumptions of authentic self-change that are deeply ingrained in our Western culture: that changes in self should be brought about by laborious ‘self-work’ in which one explores the deep layers of the self (the unconscious) and comes to realise who one really is and should become. To become oneself has been held to presuppose such a journey. While the assumed importance of self-work appears to be badly founded on closer inspection, the notions of exploring and knowing oneself appear to be more promising in fleshing out an ethical distinction between psychopharmacological and psychotherapeutic practice with the help of the concept of authenticity. Psychotherapy, to a much greater extent than psychopharmacological interventions, involves the whole profile of the self in its attempts to effect a change, not only in the temperament but also in the character of the person in question, and this is important from an ethical point of view. In the article, the concepts of self-change, authenticity, temperament and character are presented and used in order to understand and flesh out the relevant ethical differences between the practice of psychotherapy and the use of antidepressants. Looping, collective effects of psychopharmacological self-change in a cultural context are also considered in this context. (shrink)

In this article, I examine children's reported experiences with stimulant drug treatments for attention deficit hyperactivity disorder in light of bioethical arguments about the potential threats of psychotropic drugs to authenticity and moral agency. Drawing on a study that involved over 150 families in the USA and the UK, I show that children are able to report threats to authenticity, but that the majority of children are not concerned with such threats. On balance, children report that stimulants improve their capacity (...) for moral agency, and they associate this capacity with an ability to meet normative expectations. I argue that although under certain conditions stimulant drug treatment may increase the risk of a threat to authenticity, there are ways to minimise this risk and to maximise the benefits of stimulant drug treatment. Medical professionals in particular should help children to flourish with stimulant drug treatments, in good and in bad conditions. (shrink)

If a human subject knows they are being measured, this knowledge may affect their attitudes and behaviour to such an extent that it affects the measurement results as well. This broad range of effects is shared under the term ‘reactivity’. Although reactivity is often seen by methodologists as a problem to overcome, in this paper I argue that some quite extreme reactive changes may be legitimate, as long as we are measuring phenomena that are not simple biological regularities. Legitimate reactivity (...) is reactivity which does not undermine the accuracy of a measure; I show that if such reactivity were corrected for, this would unjustifiably ignore the authority of the research subject. Applying this argument to the measurement of depression, I show that under the most commonly accepted models of depression there is room for legitimate reactivity. In the first part of the paper, I provide an inventory of the different types of reactivity that exist in the literature, as well as the different types of phenomena that one could measure. In the second part, I apply my argument to the measurement of depression with the PHQ-9 survey. I argue that depending on what kind of phenomenon we consider depression to be, we will accept different kinds of reactivity. I show that both under the harmful dysfunction model and the practical kinds model, certain reactive changes in measuring depression are best seen as legitimate recharacterizations of the underlying phenomenon, and define what legitimate means in this context. I conclude that in both models, biological aspects constrain characterization, but the models are not so strict that only one concept is acceptable, leaving room for reactivity. (shrink)

It is commonly thought that mental disorder is a valid concept only in so far as it is an extension of or continuous with the concept of physical disorder. A valid extension has to meet two criteria: determination and coherence. Essentialists meet these criteria through necessary and sufficient conditions for being a disorder. Two Wittgensteinian alternatives to essentialism are considered and assessed against the two criteria. These are the family resemblance approach and the secondary sense approach. Where the focus is (...) solely on the characteristics or attributes of things, both these approaches seem to fail to meet the criteria for valid extension. However, this focus on attributes is mistaken. The criteria for valid extension are met in the case of family resemblance by the pattern of characteristics associated with a concept, and by the limits of intelligibility of applying a concept. Secondary sense, though it may have some claims to be a good account of the relation between physical and mental disorder, cannot claim to meet the two criteria of valid extension. (shrink)

Biomedicine is typically defined as the branch of medicine that is based on the principles of biology and biochemistry. A central tenet for biomedicine is the notion of disease and therapeutic specificity, i.e. the idea of tailored treatments for discrete disorders underpinned by specific pathologies. The present paper is concerned with how notions of disease and therapeutic specificity guide biomedical reasoning. To that end, the author proposes a model – the specificity triad – that draws on late philosopher and physician (...) Ludwik Fleck’s concept of “style of thought” to offer a frame for investigating the intricate process through which links between disorders, mechanisms, and therapeutics are established by biomedicine. Next by applying the specificity triad model to scrutinize research efforts in two discrete areas of medicine—psychiatry and regenerative medicine—this paper seeks to stimulate pertinent discussions in and about biomedicine. These include discussions on the ambiguous epistemic status of psychiatry within contemporary biomedicine, as well as the relationship between developmental biology — historically relatively disjointed from biomedical enterprise — and the burgeoning field of regenerative medicine. (shrink)

To what extent does payment method (managed care vs. out of pocket) influence the likelihood that an independent practitioner will assign a Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) diagnosis to a client? When a practitioner does diagnose, how does payment method influence the specific choice of a diagnostic category? Independent practitioners responded to a vignette describing a fictitious client with symptoms of depression or anxiety. In half of the vignettes, the fictitious client intended to pay (...) via managed care; in the other half, the fictitious client intended to pay out of pocket. Payment method had a very significant impact on diagnosis such that relative to out-of-pocket clients, managed care clients were much more likely to receive diagnoses and more likely to receive adjustment disorder diagnoses in particular. We discuss implications involving informed consent and other ethical issues. (shrink)

Philosophy of medicine has traditionally examined two issues: the scientific ontology for medicine and the epistemic significance of the types of evidence used in medical research. In answering each question, philosophers have typically brought to bear tools from traditional analytic philosophy. In contrast, this volume explores medical knowledge from the perspective offered by social epistemology.While many of the same issues are addressed, the approach to these issues generates both fresh questions and new insights into old debates. In addition, the broader (...) purview offered by social epistemology opens up opportunities to address new topics such as the role of consensus conferences, epistemic injustice, the value of medical knowledge, continuing medical education, and industry funding. This article situates and summarizes the contributions to this special issue. (shrink)

This article examines parallels between the increasing mental burnout and environmental overshoot in the organisational context. The article argues that there is a particular philosophy of management that connects these two phenomena of overshoot and burnout, namely productivism. As there are boundaries in all ecological processes and systems, the productivist aim of having ever more output and growth is deemed absurd. It is proposed that productivity as a management philosophy not only leads to mental ill-health in organisations but also to (...) overshoot in the environment. The article concludes that productivism, which denies the limits in utilisation of humans and other natural resources, fits poorly with circular economy and sustainability. Hence, ecological management should be complemented with a more holistic and processual view of organizations, as well as have an aim of peaceful coexistence between all earthbound objects. This signifies acknowledging and caring for human and non-human needs both now and in future by applying the idea of moderation to production of goods and services. (shrink)

Psychiatrists' accounts of clinical significance in depression Clinical significance is a crucial element in the diagnosis of mental illness, yet, it is practically untheorised and significantly under-researched. This article takes up the question of how the criterion of clinical significance is translated into psychiatric practice. More particularly, it examines how psychiatrists account for the threshold between health and depression. The paper is anchored in the constructionist view of discourse underpinned by the assumptions of critically oriented discourse analysis. It is based (...) upon a convenience sample of 39 semi-structured interviews with specialist-psychiatrists in south-western Poland. There is no discursive space for clinical significance in psychiatrists' accounts. There is no boundary, no decision to be taken as to whether the symptoms are clinically significant. Depression, invariably constructed in terms of diagnostic criteria, is always represented as fully developed, appearing out of thin air, with no period of falling ill. The article raises the issue of the validity and usefulness of psychiatric diagnosis. (shrink)

Psychotherapists in mental health institutions as a professional group are part of the medical system, and from this perspective, as representing an occupation that serves the public health interests, as well as those of the individual seeking help. Despite the different existing therapeutic approaches and diverse forms of therapy deriving from these approaches critical theories, however, consider psychotherapy as a profession with a specific jurisdictional claim and own highly specific interests. In contrast to most of the recent discussion around therapy (...) culture, in this article, I argue that sociology and social theory could benefit from an understanding of psychotherapy as a profession with a separate logic and claim for jurisdiction for mental health. Moreover, I present some general trends showing that, regarding psychotherapy, we face a concurrence of a professionalisation, and simultaneously, an already ongoing deprofessionalisation. To develop my argument, I first discuss the perspectives of sociology of the psychotherapy professions. Second, I present the potential lack of professionalism in four dimensions. Third, I discuss possible tendencies of deprofessionalisation. Finally, I conclude by pointing out the importance of theorising the psychotherapy professions for medical sociology. (shrink)

Historians and sociologists of psychiatry often claim that psychiatric diagnoses are discontinuous. That is, a particular diagnoses will be described in one way in one era and described quite differently in a different era. Historians and sociologists often draw epistemic consequences from such discontinuities, claiming that truth is pluralistic, provisional and historicised. These arguments do not readily fit in with how analytical philosophers of science approach scientific realism. I show how the pessimistic meta induction does not capture the point which (...) historians and sociologists are making but scientific perspectivism seems to capture their point much better. I then highlight conceptual innovations which scientific perspectivists add. They demarcate between truth and objective reality, they specify which type of truth they endorse and they put down constraints on possible truths. This blocks an anything goes relativism which historians and sociologists can be in danger of falling into. I highlight my argument by discussing a discontinuous episode in the history of autism. I discuss three aspects of this discontinuity and show how scientific perspectivism can portray each aspect as non-trivially true. My argument shows that we can be scientific realists about autism even if we can formulate notions of autism in quite different ways. (shrink)

Critics who are concerned over the epistemological status of psychiatric diagnoses often describe them as being constructed. In contrast, those critics usually see symptoms as relatively epistemologically unproblematic. In this paper I show that symptoms are also constructed. To do this I draw upon the demarcation between data and phenomena. I relate this distinction to psychiatry by portraying behaviour of individuals as data and symptoms as phenomena. I then draw upon philosophers who consider phenomena to be constructed to argue that (...) symptoms are also constructed. Rather than being ready made in the world I show how symptoms are constructs we apply to the world. I highlight this with a historical example and describe methodological constraints on symptom construction. I show the epistemic problems with psychiatric diagnoses are also applicable to symptoms. Following this, I suggest that critics of psychiatric diagnoses should extend their criticism to symptoms or, if they still believe symptoms are relatively epistemologically unproblematic, should rethink their concerns over psychiatric diagnoses. (shrink)

This article examines the cultural practices through which a group of professionals infuse their work and community with charisma. Although previous research has theorized the “charisma of office” (Weber 1978), we know little about how the occupants of such offices sustain it. I focus on a group of psychoanalytically-inclined psychotherapists, whose field, despite its early charismatic beginnings, has been especially embattled in recent decades. Drawing on ethnographic and interview data, I reveal how they share stories emphasizing their “idealization” by others, (...) draw boundaries between their professional and private lives to manage their work identities, and perform interpersonal affective work that shores up their claims to extraordinary abilities. Together, these cultural practices constitute charisma within the professional group. This article thus makes a case that, as expertise becomes increasingly contested, we must look beyond social organization and the evidentiary bases of knowledge to understand professional authority. (shrink)

This article does not directly consider the feelings and emotions that occur in mental illness. Rather, it concerns a higher level methodological question: To what extent is an analysis of feelings and felt emotions of importance for psychiatric classification? Some claim that producing a phenomenologically informed descriptive psychopathology is a prerequisite for serious taxonomic endeavor. Others think that classifications of mental disorders may ignore subjective experience. A middle view holds that classification should at least map the contours of the phenomenology (...) of mental illness. This article examines these options. I conclude that it is not true that phenomenology is a logical prerequisite for classification, nor even that classification should necessarily respect phenomenological boundaries, but that detailed phenomenological examination can sometimes inform classification. (shrink)

This paper asks what it means to say that a disorder is a “real” disorder and then considers whether culture-bound syndromes are real disorders. Following J.L. Austin I note that when we ask whether some supposed culture-bound syndrome is a real disorder we should start by specifying what possible alternatives we have in mind. We might be asking whether the reported behaviours genuinely occur, that is, whether the culture-bound syndrome is a genuine phenomenon as opposed to a myth. We might (...) be wondering whether the condition should rightly be considered a disorder, as opposed to some sort of non-disorder condition. We might want to know whether the culture-bound syndrome is really a distinct disorder, in the sense that scientific classification systems should include it as a separate category, or whether it is just a variant of a universally occurring disorder. I argue that some specific difficulties can arise with determining whether a culture-bound syndrome is a real disorder in each of these three senses. However, the frequent assumption that real disorders will necessarily occur universally, and that those that occur only in certain environments are suspicious is not generally justified. (shrink)

Is it ever right to prescribe placebos to patients in clinical practice? The General Medical Council is ambivalent about the issue; the American Medical Association asserts that placebos can be administered only if the patient is (somehow) ‘informed’. The potential problem with placebos is that they may involve deception: indeed, if this is the case, an ethical tension arises over the patient's autonomy and the physician's requirement to be open and honest, and the notion that medical care should be the (...) primary concern. This paper examines the case of depression as an entry point for understanding the complexities of the prescription of placebos. Recent important meta-analyses of antidepressants claim that they are not significantly more effective in a clinical setting than placebos. Given that antidepressants have numerous adverse side effects and are hugely expensive, this provocative research has serious potential ethical and practical implications for patients and medical providers. Should placebos be prescribed in place of antidepressants? The case of depression highlights another important issue which medical ethical codes have hitherto overlooked: well-being is not synonymous with being realistic about oneself, one's circumstances and the future. While severely depressed individuals are unduly pessimistic about themselves and the world around them, treatment of depressed individuals can be deemed successful when patients have successfully attained those positive illusions that are indicative of psychological health. This is exactly what successful psychological treatments of depression seem to achieve. It is therefore possible that there may be a limited unavoidable role for deception in medicine. (shrink)

The ability to (re)classify populations is a key component of state power, but not all new state classifications actually succeed in changing how people are categorized and governed. This article examines the French state’s partly unsuccessful project in 2005 to use a new classification—“psychic handicap”—to ensure that people with severe mental disorders received services and benefits from separate agencies based on a designation of being both “mentally ill” and “disabled.” Previous research has identified how new classifications can be impeded by (...) cultural and cognitive barriers to their adoption and struggles between professionals or administrators over their implementation. Drawing on 186 interviews, archival sources, and 13 months of observations across different French bureaucracies, I expand on this literature in two ways. First, I use the case of psychic handicap to argue that a new classification can also fail to achieve its intended effect when it constitutes a bureaucratically split personality—a combination of classifications that imply that individuals belong to two, mutually exclusive kinds of people. I show how psychic handicap embodied contradictory expectations about the behavior, characteristics, and institutional trajectory of people with mental disorders. Second, I identify how bureaucrats resolved these contradictions through mechanisms of refractory looping, outsourcing expertise, and classification by default, which in this case led to the reclassification of this population as simply “mentally ill.” This framework calls attention to how practical inconsistencies can limit the impact of new classifications, even absent overt resistance to their elaboration or implementation. (shrink)

This paper aims at considering the conceptual status of feeding and eating disorders (FEDs). Now that the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has changed the classification and some relevant criteria of FEDs, it is particularly relevant to evaluate their psychiatric framework and their status as mental disorders. I focus my efforts on addressing only one specific question: Do FEDs fit the DSM-5 general definition of mental disorder? In DSM-5 a mental disorder is defined as a syndrome that (...) reflects adysfunctionand is usually associated with significantdistress or disability. More importantly, there is an explicit statement saying thatallmental disorders listed in the manual must meet the requirements highlighted by the general definition. Thus, I evaluate whether or not FEDs are really meant to reflect a dysfunction and are usually associated with significant distress or disability. (shrink)

The general concept of mental disorder specified in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders is definitional in character: a mental disorder might be identified with a harmful dysfunction. The manual also contains the explicit claim that each individual mental disorder should meet the requirements posed by the definition. The aim of this article is two-fold. First, we shall analyze the definition of the superordinate concept of mental disorder to better understand what necessary criteria actually (...) characterize such a concept. Second, we shall consider the concepts of some individual mental disorders and show that they are in tension with the definition of the superordinate concept, taking pyromania and narcissistic personality disorder as case studies. Our main point is that an unexplained and not-operationalized dysfunction requirement that is included in the general definition, while being systematically violated by the diagnostic criteria of specific mental disorders, is a logical error. Then, either we unpack and operationalize the dysfunction requirement, and include explicit diagnostic criteria that can actually meet it, or we simply drop it. (shrink)

The dominance of the medical-model in American psychiatry over the last 30 years has resulted in the subsequent decline of the “talking cure”. In this paper, we identify a number of problems associated with medicalized psychiatry, focusing primarily on how it conceptualizes the self as a de-contextualized set of symptoms. Drawing on the tradition of hermeneutic phenomenology, we argue that medicalized psychiatry invariably overlooks the fact that our identities, and the meanings and values that matter to us, are created and (...) constituted by our dialogical relations with others. While acknowledging the importance of medical and pharmaceutical interventions, we suggest that it is only by means of the dialogical interplay of the talking cure that the client can both recognize unhealthy and self-defeating ways of being and be opened up to the possibility of new meanings and self-interpretations. (shrink)

The rise of medically unexplained conditions like fibromyalgia and chronic fatigue syndrome in the United States looks remarkably similar to the explosion of neurasthenia diagnoses in the late nineteenth century. In this paper, I argue the historical connection between neurasthenia and today’s medically unexplained conditions hinges largely on the uncritical acceptance of naturalism in medicine. I show how this cultural acceptance shapes the way in which we interpret and make sense of nervous distress while, at the same time, neglecting the (...) unique social and historical forces that continue to produce it. I draw on the methods of hermeneutic philosophy to expose the limits of naturalism and forward an account of health and illness that acknowledges the extent to which we are always embedded in contexts of meaning that determine how we experience and understand our suffering. (shrink)

Autism is a neurodevelopmental disorder featuring severe social and communicative deficits. Cognitive impenetrability is the inability of systems to be affected by an individual’s beliefs and desires. Individuals with autism have delayed performance on "mindreading" tasks. Mindreading is the interpretation of others which enables successful social interactions. This task performance is not correlated with "everyday" social function in autism. These deficits are in contrast with general intelligence and reasoning abilities within the normal range, resistant to cognitive behavioral training, and partially (...) attributable to atypical social predispositions. This suggests individuals with autism perform social tasks differently than typicals. I argue that this mindreading deficit is cognitively impenetrable, then position this deficit within a theoretical framework, enactivism, emphasizing cognitive embodiment and inseparability of social comprehension and action. This framework helps explain the cognitive impenetrability of these social deficits by "locating" failure to penetrate in individuals' failure to properly interact with the environment. (shrink)

The vagueness or imprecision of ‘the normal’ allows it to be exploited for various purposes and political ends. It is conspicuous in both medicine and athletics; I am going to try to say something about the normal in each of these areas. In medicine the idea of the normal is often deployed in understanding what constitutes disease and hence, as some see it, in determining the role of physicians, in determining what is or ought to be covered by insurance, and (...) in underwriting certain views on social justice. In athletics the use of performance enhancing substances raises different sorts of questions about the normal, especially when it comes to deciding what constitutes an enhancement and which enhancements, if any, are acceptable. (shrink)

The recurring claim that the construct of psychopathy is value laden often is not qualified in enough detail. The chapters in this part of the volume, instead, investigate in depth the role and significance of values in different aspects of the construct of psychopathy. Following these chapters, but also by offering a background to them, we show how certain values are involved in the characterisation of psychopathy, inform societal needs satisfied by this construct, and have a central role in determining (...) whether psychopathy is a mental disorder. Moreover, we relate this description to our criticism of the view that the entrenchment of the notion of psychopathy with values in principle renders it irreconcilable with sound psychiatric theory and practice. However, we also recognize that the value-ladenness of psychopathy leaves open other important challenges. Meeting them needs addressing interdisciplinary interrelated issues that have empirical, normative, and theoretical dimensions. (shrink)

A large part of the controversy surrounding the publication of DSM-5 stems from the possibility of replacing the purely descriptive approach to classification favored by the DSM since 1980. This paper examines the question of how mental disorders should be classified, focusing on the issue of whether the DSM should adopt a purely descriptive or theoretical approach. I argue that the DSM should replace its purely descriptive approach with a theoretical approach that integrates causal information into the DSM’s descriptive diagnostic (...) categories. The paper proceeds in three sections. In the first section, I examine the goals (viz., guiding treatment, facilitating research, and improving communication) associated with the DSM’s purely descriptive approach. In the second section, I suggest that the DSM’s purely descriptive approach is best suited for improving communication among mental health professionals; however, theoretical approaches would be superior for purposes of treatment and research. In the third section, I outline steps required to move the DSM towards a hybrid system of classification that can accommodate the benefits of descriptive and theoretical approaches, and I discuss how the DSM’s descriptive categories could be revised to incorporate theoretical information regarding the causes of disorders. I argue that the DSM should reconceive of its goals more narrowly such that it functions primarily as an epistemic hub that mediates among various contexts of use in which definitions of mental disorders appear. My analysis emphasizes the importance of pluralism as a methodological means for avoiding theoretical dogmatism and ensuring that the DSM is a reflexive and self-correcting manual. (shrink)

En este artículo estudio una estrategia de gobierno a la que denomino hermenéutica psiquiátrica de sí. Para comprenderla analizo los estudios que Foucault dedica al tema de la enunciación de la verdad y su relación con el gobierno de sí y el de los otros. Considerando las diferencias entre el cuidado de sí greco-romano, la hermenéutica cristiana de sí y la hermenéutica psiquiátrica de sí, examino cómo se articulan, en el campo de la psiquiatría, los ejes delimitados por el gobierno (...) de los otros, el gobierno de sí y la enunciación de una verdad sobre nosotros mismos como identidad psiquiatrizada. (shrink)