Thomas, Bracken, and Timimi (2012) make an important contribution in critiquing the extent to which the profession of psychiatry can be so bureaucratic that patients are treated as problems to be solved in an ‘efficient’ assembly line fashion rather than as individual persons. The trouble with bureaucracies is that they promote a cold and impersonal accounting approach in which critical reflection on purposes is circumvented by decision-making algorithms (Zachar and Bartlett 2009). Psychotherapy treatment manuals definitely satisfy the bureaucratic instinct, and (...) the fifteen-minute medication management session even more so (Harris 2011). Ideally, evidence-based medicine (EBM) should be used to promote the goals of .. (shrink)
In the conclusion to this multi-part article I first review the discussions carried out around the six essential questions in psychiatric diagnosis – the position taken by Allen Frances on each question, the commentaries on the respective question along with Frances’ responses to the commentaries, and my own view of the multiple discussions. In this review I emphasize that the core question is the first – what is the nature of psychiatric illness – and that in some manner all further (...) questions follow from the first. Following this review I attempt to move the discussion forward, addressing the first question from the perspectives of natural kind analysis and complexity analysis. This reflection leads toward a view of psychiatric disorders – and future nosologies – as far more complex and uncertain than we have imagined. (shrink)
In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role (...) of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article will take up the first two questions. With the first question, invited commentators express a range of opinion regarding the nature of psychiatric disorders, loosely divided into a realist position that the diagnostic categories represent real diseases that we can accurately name and know with our perceptual abilities, a middle, nominalist position that psychiatric disorders do exist in the real world but that our diagnostic categories are constructs that may or may not accurately represent the disorders out there, and finally a purely constructivist position that the diagnostic categories are simply constructs with no evidence of psychiatric disorders in the real world. The second question again offers a range of opinion as to how we should define a mental or psychiatric disorder, including the possibility that we should not try to formulate a definition. The general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances. (shrink)
In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role (...) of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article took up the first two questions. Part II will take up the second two questions. Question 3 deals with the question as to whether DSM-V should assume a conservative or assertive posture in making changes from DSM-IV. That question in turn breaks down into discussion of diagnoses that depend on, and aim toward, empirical, scientific validation, and diagnoses that are more value-laden and less amenable to scientific validation. Question 4 takes up the role of pragmatic consideration in a psychiatric nosology, whether the purely empirical considerations need to be tempered by considerations of practical consequence. As in Part 1 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances. (shrink)
In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role (...) of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part 1 of this article took up the first two questions. Part 2 took up the second two questions. Part 3 now deals with Questions 5 & 6. Question 5 confronts the issue of utility, whether the manual design of DSM-III and IV favors clinicians or researchers, and what that means for DSM-5. Our final question, Question 6, takes up a concluding issue, whether the acknowledged problems with the earlier DSMs warrants a significant overhaul of DSM-5 and future manuals. As in Parts 1 & 2 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances. (shrink)
In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role (...) of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM – whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article took up the first two questions. Part II will take up the second two questions. Question 3 deals with the question as to whether DSM-V should assume a conservative or assertive posture in making changes from DSM-IV. That question in turn breaks down into discussion of diagnoses that depend on, and aim toward, empirical, scientific validation, and diagnoses that are more value-laden and less amenable to scientific validation. Question 4 takes up the role of pragmatic consideration in a psychiatric nosology, whether the purely empirical considerations need to be tempered by considerations of practical consequence. As in Part 1 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances. (shrink)
We compare astronomers' removal of Pluto from the listing of planets and psychiatrists' removal of homosexuality from the listing of mental disorders. Although the political maneuverings that emerged in both controversies are less than scientifically ideal, we argue that competition for "scientific authority" among competing groups is a normal part of scientific progress. In both cases, a complicated relationship between abstract constructs and evidence made the classification problem thorny.
When i was in graduate school, I inadvertently walked in on a fellow student taking his comprehensive exams. He was extremely frustrated because two of the questions asked about conceptual issues in personality and personality disorders. This student was not expecting such questions and considered them to be unfair. I knew other students in that same program who would have considered it a gift to get such “interesting” questions. Those clinical and counseling psychologists with theoretical–philosophical interests are often attracted to (...) the topics of personality and personality disorders. It has, therefore, puzzled me why these same topics are largely ignored by those philosophers who study the conceptual issues of .. (shrink)
In the sociopolitical domain, psychiatry runs the risk of excusing immoral behavior by claiming it is ‘disordered’ and, conversely, of assigning moral blame to what are more properly considered illnesses (O’Malley 2004; Wiseman 1961). This debate is often played out in terms of the relationship between psychotic states and crimes such as murder. Examples include debates about whether Andrea Yates should have been executed for filicide. A similar controversy would have likely emerged had Seung-Hui Cho lived after committing mass murder (...) at Virginia Tech University. A longstanding problem in psychiatry, questions of whether certain people are mad or bad continue to haunt the field. In 1994, Susan Smith of .. (shrink)
We are thankful for the opportunity to reflect more on the difficult problem of the relationship between moral evaluations and the construct of personality disorders in response to the commentaries by Mike Martin and Louis Charland. We begin by emphasizing to readers that this important problem is complicated by the different perspectives of the various disciplines involved, especially, philosophy, psychiatry, and psychology. Incredulity, anger, and dismay are among the reactions we encountered in discussions of these issues, especially with some mental (...) health professionals. Strong reactions on either side of a disciplinary divide occasionally present barriers to a dispassionate discussion of the topic. .. (shrink)
The thesis of this article is that an attitude akin to pragmatism is internal to the scientific enterprise itself, and as a result many scientists will make the same types of non-essentialistic interpretations of their subject matter that are made by pragmatists. This is demonstrably true with respect to those scientists who study the biological basis of emotion such as Panksepp, LeDoux, and Damasio. Even though these scientists are also influenced by what cognitive psychologists call the essentialist bias, their research (...) programs are coherent with Peter Zachar?s rejection of natural kinds in favor of practical kinds. When the confrontation with complexity leads a scientist to offer non-essentialist interpretations, two popular options are to go eliminativist or go nominalist. Pragmatists prefer the nominalistic option, and we provide reasons for suggesting that scientists should as well. (shrink)
