The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) has for decades been a locus of dispute between ardent defenders of its scientific validity and vociferous critics who charge that it covertly cloaks disputed moral and political judgments in scientific language. This essay explores Alasdair MacIntyre's tripartite typology of moral reasoning—"encyclopedia," "genealogy," and "tradition"—as an analytic lens for appreciation and critique of these debates. The DSM opens itself to corrosive neo-Nietzschean "genealogical" critique, such an analysis holds, (...) only insofar as it is interpreted as a presumptively objective and context-independent encyclopedia free of the contingencies of its originating communities. A MacIntyrean tradition-constituted understanding of the DSM, on the other hand, helpfully allows psychiatricnosology to be understood both as "scientific" and, simultaneously, as inextricable from the political and moral interests—and therefore the moral successes and moral failures—of the psychiatric guild from which it arises. (shrink)
Psychiatry is becoming a cognitive neuroscience. This new paradigm not only aims to give new ways for explaining mental diseases by naturalizing them, but also to have an influence on different levels of psychiatric norms. We tried here to verify whether a biological paradigm is able to fulfill this normative goal. We analyzed three main normative assumptions that is to say the will of giving psychiatry a valid nosology, a rigorous definition of what is a mental disease, and (...) new tools for destigmatizing mentally ill patients. Although these different kinds of normativity are very heterogeneous, we must conclude that, in all these cases, biological psychiatry is a failure, in part because of a lack of epistemological conceptualization. (shrink)
The Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association, currently in its fourth edition and considered the reference for the characterization and diagnosis of mental disorders, has undergone various developments since its inception in the mid-twentieth century. With the fifth edition of the DSM presently in field trials for release in 2013, there is renewed discussion and debate over the extent of its relative successes - and shortcomings - at iteratively incorporating scientific evidence on the often ambiguous (...) nature and etiology of mental illness. Given the power that the DSM has exerted both within psychiatry and society at large, this essay seeks to analyze variations in content and context of various editions of the DSM, address contributory influences and repercussion of such variations on the evolving landscape of psychiatry as discipline and practice over the past sixty years. Specifically, we document major modifications in the definition, characterization, and classification of mental disorders throughout successive editions of the DSM, in light of shifting trends in the conceptualization of psychopathology within evolving schools of thought in psychiatry, and in the context of progress in behavioral and psychopharmacological therapeutics over time. We touch upon the social, political, and financial environments in which these changes took places, address the significance of these changes with respect to the legitimacy (and legitimization) of what constitutes mental illness and health, and examine the impact and implications of these changes on psychiatric practice, research, and teaching. We argue that problematic issues in psychiatry, arguably reflecting the large-scale adoption of the DSM, may be linked to difficulties in formulating a standardized nosology of psychopathology. In this light, we highlight 1) issues relating to attempts to align the DSM with the medical model, with regard to increasing specificity in the characterization of discrete mental disease entities and the incorporation of neurogenetic, neurochemical and neuroimaging data in its nosological framework; 2) controversies surrounding the medicalization of cognition, emotion, and behavior, and the interpretation of subjective variables as 'normal' or 'abnormal' in the context of society and culture; and 3) what constitutes treatment, enablement, or enhancement - and what metrics, guidelines, and policies may need to be established to clarify such criteria. (shrink)
This multidisciplinary collection explores three key concepts underpinning psychiatry -- explanation, phenomenology, and nosology -- and their continuing relevance in an age of neuroimaging and genetic analysis. An introduction by Kenneth S. Kendler lays out the philosophical grounding of psychiatric practice. The first section addresses the concept of explanation, from the difficulties in describing complex behavior to the categorization of psychological and biological causality. In the second section, contributors discuss experience, including the complex and vexing issue of how (...) self-agency and free will affect mental health. The third and final section examines the organizational difficulties in psychiatricnosology and the instability of the existing diagnostic system. Each chapter has both an introduction by the editors and a concluding comment by another of the book's contributors. Contributors: John Campbell, Ph.D.; Thomas Fuchs, M.D., Ph.D.; Shaun Gallagher, Ph.D.; Kenneth S. Kendler, M.D.; Sandra D. Mitchell, Ph.D.; Dominic P. Murphy, Ph.D.; Josef Parnas, M.D., Dr.Med.Sci.; Louis A. Sass, Ph.D.; Kenneth F. Schaffner, M.D., Ph.D.; James F. Woodward, Ph.D.; Peter Zachar, Ph.D. (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 psychiatricnosology, 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 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 psychiatricnosology, 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 this article I examine some of the issues involved in taking psychiatric disorders as natural kinds. I begin by introducing a permissive model of natural kind-hood that at least prima facie seems to allow psychiatric disorders to be natural kinds. The model, however, hinges on there in principle being some grounding that is shared by all members of a kind, which explain all or most of the additional shared projectible properties. This leads us to the following question: (...) what grounding do psychiatric disorders qua natural kinds have? My principal method for examining the issue is a case study of a particular psychiatric disorder: the so-called “apathetic children.” I argue that there appear to be at least two competing models that both appeal to non-organic a grounding of the disorder. However, for other psychiatric disorders, such as Alzheimer’s disease, the evidence points toward an organic explanation of the disorder. I contend that what unites psychiatric disorders is not a distinctive type of grounding that all psychiatric disorders share, but the distinctive set of determinable properties that is shared by all psychiatric disorders. (shrink)
Psychiatric ethics as professional and biomedical ethics -- The distinctiveness of the psychiatric setting -- Psychiatric ethics as virtue ethics -- Elements of a gender-sensitive ethics for psychiatry -- Some virtues for psychiatrists -- Character and social role -- Case studies in psychiatric virtues.
Ethical issues are pivotal to the practice of psychiatry. Anyone involved in psychiatric practice and mental healthcare has to be aware of the range of ethical issues relevant to their profession. An increased professional commitment to accountability, in parallel with a growing "consumer" movement has paved the way for a creative engagement with the ethical movement. The bestselling 'Psychiatric Ethics' has carved out a niche for itself as the major comprehensive text and core reference in the field, covering (...) a range of complex ethical dilemmas which face clinicians and researchers in their everyday practice. This new edition takes a fresh look at recent trends and developments at the interface between ethics and psychiatric practice. Coming ten years after the third edition, the editors have observed several emerging aspects of psychiatric practice requiring coverage, as a result, 5 new chapters have been added, including cutting edge topics - such as neuroethics. All other chapters have been fully revised and updated. The book will continue to be essential reading for psychiatrists, psychologists, other mental health professionals, and bioethicists, as well as of interest to policy makers, managers and lawyers. (shrink)
In Two Minds is a practical casebook of problem solving in psychiatric ethics. Written in a lively and accessible style, it builds on a series of detailed case histories to illustrate the central place of ethical reasoning as a key competency for clinical work and research in psychiatry. Topics include risk, dangerousness and confidentiality; judgements of responsibility; involuntary treatment and mental health legislation; consent to genetic screening; dual role issues in child and adolescent psychiatry; needs assessment; cross-cultural and gender (...) issues; rational and irrational suicide; shared decision making in multi-agency teams, and the growing role of the user's voice in psychiatry. Key ethical concepts are carefully introduced and explained. The text is richly supported by detailed guides for further reading. There are separate chapters on teaching psychiatric ethics, including a sample seminar, and on writing a research ethics application. Each case history and discussion is followed by a critical commentary from a practitioner with relevant experience. Jim Birley adds a comparative international perspective on psychiatric ethics. Cartoons by Johnny Cowee provide punchy counterpoint! In Two Minds is the sister volume to the third edition of Sidney, Paul Chodoff and Steven Green's highly successful Psychiatric Ethics. In providing a bridge between theory and practice, it will be essential reading for everyone concerned with improving standards in mental health care. (shrink)
This article aims to clarify the notion of a psychiatric disability. The article uses conceptual analysis, examining and applying established definitions of (general) disability to psychiatric disabilities. This analysis reveals that disability as inability to perform according to expectations or norms is related to impairment as deviation from the (statistical) norm, while disability as inability to achieve (personal) goals is related to impairment as deviation from the (personal) ideal. These two views of impairment and disability are distinct from (...) the self-organization view of impairment as disrupted self-creation or disrupted self-repair and of disability as disrupted whole person self-compensation (in relation to an impairment). All these three views of disability pertain to psychiatric disability. Although there is nothing necessarily psychiatric about psychiatric disability other than the psychiatric impairment related to it, the life course and life circumstances typical of many people with (severe) psychiatric disorders may lead to disability and may thus confer some (psychiatric) specificity on this disability. This analysis may facilitate research on specific psychiatric disabilities and a broader scope for psychiatric rehabilitation. (shrink)
An evolutionary theory of schizophrenia needs to address all symptoms associated with the condition. Burns' framework could be extended in a way embracing behavioural signs such as catatonia. Burns' theory is, however, not specific to schizophrenia. Since no one single symptom exists that is pathognomonic for “schizophrenia,” an evolutionary proposal of psychiatric disorders raises the question whether our anachronistic psychiatricnosology warrants revision.
For most of this past century, scholarship on the topics of personal- ity and emotion has emerged from the humanities and social sciences. In the past decade, a remarkable change has occurred in the influence of neuro- science on the conceptualization and study of these phenomena. This article ar- gues that the categories that have emerged from psychiatricnosology and descriptive personality theory may be inadequate, and that new categories and dimensions derived from neuroscience research may produce a (...) more tractable parsing of this complex domain. The article concludes by noting that the dis- covery of these biological differences among individuals does not imply that the origins of these differences lie in heritable influences. Experiential shaping of the brain circuitry underlying emotion is powerful. The neural architecture provides the final common pathway through which culture, social factors, and genetics all operate together. (shrink)
The DSM-IV, like its predecessors, will be a major influence on American psychiatry. As a consequence, continuing analysis of its assumptions is essential. Review of the manuals as well as conceptually-oriented literature on DSM-III, DSM-III-R, and DSM-IV reveals that the authors of these classifications have paid little attention to the explicit and implicit value commitments made by the classifications. The response to DSM criticisms and controversy has often been to incorporate more scientific diversity into the classification, instead of careful inquiry (...) and assessment of the principal values that drive the nosologic process. Implications for psychiatric science and future DSM classifications are discussed. Keywords: DSM-III, DSM-III-R, DSM-IV, Psychiatric Classification, values CiteULike Connotea Del.icio.us What's this? (shrink)
Murphy (2006) criticizes psychiatricnosology from the perspective of the philosophy of science, arguing that the model of pathology as encapsulated in the Diagnostic and Statistical Manual of Mental Disorders reflects a folk conception of the mental, and of malfunctioning, that is inadequately integrated with cognitive and behavioral neuroscience. The present paper supports this view through a case study of research on pathological gambling. It argues that recent modeling based on fMRI studies and behavioral genetics suggests a stipulative, (...) non-seamless reduction of pathological gambling to a specific disorder of the mesolimbic dopamine system. This argument is agnostic as between prior philosophical commitments to realism or empiricism. (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)
The concept of hysteria is traced from Hippocrates, where it was thought to be caused by a wandering uterus, through Galen and up to Freud. Throughout the history of medicine from the early Greeks up to the end of the nineteenth century, the definition and diagnosis of hysteria had a function similar to that found in the persecution of witchcraft: it sought to eradicate the outbursts of nonconforming and emotionally threatening conduct of women. At the beginning of the twentieth century, (...) however, the category virtually disappears from psychiatric nosologies. Keywords: Freud, hysteria, nosology, witchcraft CiteULike Connotea Del.icio.us What's this? (shrink)
This paper examines Ian Hacking's analysis of the looping effects of psychiatric classifications, focusing on his recent account of interactive and indifferent kinds. After explicating Hacking's distinction between 'interactive kinds' (human kinds) and 'indifferent kinds' (natural kinds), I argue that Hacking cannot claim that there are 'interactive and indifferent kinds,' given the way that he introduces the interactive-indifferent distinction. Hacking is also ambiguous on whether his notion of interactive and indifferent kinds is supposed to offer an account of classifications (...) or objects of classification. I argue that these conceptual difficulties show that Hacking's account of interactive and indifferent kinds cannot be based on - and should be clearly separated from - his distinction between interactive kinds and indifferent kinds. In clarifying Hacking's account, I argue that interactive and indifferent kinds should be regarded as objects of classification (i.e., kinds of people) that can be identified with reference to a law-like biological regularity and are aware of how they are classified. Schizophrenia and depression are discussed as examples. I subsequently offer reasons for resisting Hacking's claim that the objects of classification in the human sciences - as a result of looping effects - are 'moving targets'. (shrink)
Abstract Recently, some philosophers of psychiatry (viz., Rachel Cooper and Dominic Murphy) have analyzed the issue of psychiatric classification. This paper expands upon these analyses and seeks to demonstrate that a consideration of the history of the Diagnostic and Statistical Manual of Mental Disorders (DSM) can provide a rich and informative philosophical perspective for critically examining the issue of psychiatric classification. This case is intended to demonstrate the importance of history for philosophy of psychiatry, and more generally, the (...) potential benefits of historically-informed approaches to philosophy of science. (shrink)
In psychiatry some disorders of cognition are distinguished from instances of normal cognitive functioning and from other disorders in virtue of their surface features rather than in virtue of the underlying mechanisms responsible for their occurrence. Aetiological considerations often cannot play a significant classificatory and diagnostic role, because there is no sufficient knowledge or consensus about the causal history of many psychiatric disorders. Moreover, it is not always possible to uniquely identify a pathological behaviour as the symptom of a (...) certain disorder, as disorders that are likely to differ both in their causal histories and in their overall manifestations may give rise to very similar patterns of behaviour. -/- Consider delusions as an example. It wouldn’t be correct to define delusions as those beliefs people form as a result of a neurobiological deficit and a hypothesis-evaluation deficit (as some versions of the two-factor theory of delusions suggest), because for some delusions no neurobiological deficit may be found, and reasoning biases and motivational factors may be contributors to the formation of the delusion (e.g. McKay et al., 2005). Moreover, it would be a mistake to define delusions as symptoms of schizophrenia alone, because they occur also in other disorders, including dementia, amnesia, and delusional disorders. Thus, aetiological considerations may appear in the description and analysis of delusions, but do not feature prominently in their definition. -/- In this paper I argue that the surface features used as criteria for the classification and diagnosis of disorders of cognition are often epistemic in character. I shall offer two examples: confabulations and delusions are defined as beliefs or narratives that fail to meet standards of accuracy and justification. Although classifications and diagnoses based on features of people’s observable behaviour are necessary at these early stages of neuropsychiatric research, given the variety of conditions in which certain phenomena appear, I shall attempt to show that current epistemic accounts of confabulations and delusions have limitations. Epistemic criteria can guide both research and clinical practice, but fail to provide sufficient conditions for the identification of delusions and confabulations, and fail to demarcate pathological from non-pathological narratives or beliefs. -/- Another limitation of current epistemic accounts – which I shall not address here – is the excessive focus on epistemic faults of confabulations and delusions at the expense of their epistemically neutral or advantageous features (see Bortolotti and Cox, 2009). This may lead to a misconception of delusions and confabulations, and to an oversimplification in the assessment of the needs of people who require clinical treatment for their psychotic symptoms. (shrink)
The goal of this article is to put to the fore the importance and the relevance of the “second persons” in the framework of the relational ethics where the person has being related as a primacy over the individual as an isolated subject. While using the psychiatric team of an emergency unit (E.R.I.C.) as a leading thread we seek to show the anthropology of being related, which underlines the practical ethics of such emergency team.
The public, mental health consumers, as well as mental health practitioners wonder about what kinds of values mental health professionals hold, and what kinds of values influence psychiatric diagnosis. Are mental disorders socio-political, practical, or scientific concepts? Is psychiatric diagnosis value-neutral? What role does the fundamental philosophical question "How should I live?" play in mental health care? In his carefully nuanced and exhaustively referenced monograph, psychiatrist and philosopher of psychiatry John Z. Sadler describes the manifold kinds of values (...) and value judgements involved in psychiatric diagnosis and classification systems like the DSM. Professor Sadler takes the reader on a fascinating conceptual tour of the inner workings of psychiatric diagnosis, considering the role of science, culture, sexuality, politics, gender, technology, human nature, patienthood, and professions in building his vision of a more humane psychiatric diagnostic process. (shrink)
A number of philosophers have argued that psychiatric delusions threaten Donald Davidson's rationalist account of intentional agency. I argue that a careful look at both Davidson's account and psychiatric delusions shows that, in fact, the two are perfectly compatible. Indeed, a Davidsonian perspective on psychiatric delusions proves remarkably illuminating.
I show how much psychiatric disability is informed by trauma, marginalization, sexist norms, social inequalities, concepts of irrationality and normalcy, oppositional mind-body dualism, and mainstream moral values. Drawing on feminist discussion of physical disability, I present a feminist theory of psychiatric disability that serves to liberate not only those who are psychiatrically disabled but also the mind and moral consciousness restricted in their ranges of rational possibilities.
Kanaan and McGuire elegantly describe three challenges facing the use of fMRI to uncover cognitive mechanisms. They shows how these challenges ramify in the case of identifying the mechanisms responsible for psychiatric disorders. In this commentary, I would like to raise another difficulty for fMRI that also appears to ramify in similar cases. This is that there are good reasons for doubting one of the assumptions on which many fMRI studies are based: that neural mechanisms are always and everywhere (...) sufficient for cognition. I suggest that in the case of the mechanisms underlying psychiatric disorders, this assumption should be doubted. I do not dispute that a malfunctioning neural mechanism is likely to be a necessary component of a psychiatric disorder—as Kanaan and McGuire say, the experimental evidence from cognitive neuropsychiatry gives us excellent reasons to think that this is so. My question is whether a story only in terms of these neural mechanisms is sufficient to explain the mechanism of a psychiatric disorder. Is the reduction, projected by cognitive neuropsychiatry, of psychiatric disorders to disorders in neural functioning even in principle possible? Drawing on recent concerns about the location of mental states, I argue that such a reduction is likely to fail. Even if the considerable problems raised by Kanaan and McGuire for fMRI could be addressed, we have no reason to think that the mechanisms involved in psychiatric disorders are entirely neural, and that fMRI, or even a perfect science-fiction brain-scanner, would be capable of uncovering them. Psychiatric disorders, like numerous other cognitive processes, are liable to cross the brain–world boundary in such a promiscuous way as to be resistant to neural reduction. (shrink)
Progress in psychiatry depends on accurate definitions of disorders. As long as there are no known biologic markers available that are highly specific for a particular psychiatric disorder, clinical practice as well as scientific research is forced to appeal to clinical symptoms. Currently, the nosology of obsessive-compulsive disorder is being reconsidered in view of the publication of DSM-V. Since our diagnostic entities are often simplifications of the complicated clinical profile of patients, definitions of psychiatric disorders are imprecise (...) and always indeterminate. This urges researchers and clinicians to constantly think and rethink well-established definitions that in psychiatry are at risk of being fossilised. In this paper, we offer an alternative view to the current definition of obsessive-compulsive disorder from a phenomenological perspective.TranslationThis article is translated from Dutch, originally published in [Handbook Obsessive-compulsive disorders, Damiaan Denys, Femke de Geus (Eds.), (2007). De Tijdstroom uitgeverij BV, Utrecht. ISBN13: 9789058980878.]. (shrink)
This paper analyses ethical issues in forensic psychiatric research on mentally disordered offenders, especially those detained in the psychiatric treatment system. The idea of a 'dual role' dilemma afflicting forensic psychiatry is more complicated than acknowledged. Our suggestion acknowledges the good of criminal law and crime prevention as a part that should be balanced against familiar research ethical considerations. Research aiming at improvements of criminal justice and treatment is a societal priority, and the total benefit of studies has (...) to be balanced against the risks for research subjects inferred by almost all systematic studies. Direct substantial risks must be balanced by health benefits, and normal informed consent requirements apply. When direct risks are slight, as in register-based epidemiology, lack of consent may be counter-balanced by special measures to protect integrity and the general benefit of better understanding of susceptibility, treatment and prevention. Special requirements on consent procedures in the forensic psychiatric context are suggested, and the issue of the relation between decision competence and legal accountability is found to be in need of further study. The major ethical hazard in forensic psychiatric research connects to the role of researchers as assessors and consultants in a society entertaining strong prejudices against mentally disordered offenders. (shrink)
Extant business research has not addressed the ethical treatment of individuals with psychiatric disabilities. This article will describe previous research on individuals with psychiatric disabilities drawn from rehabilitation, psychological, managerial, legal, as well as related business ethics writings before presenting a framework that illustrates the dynamics of (un)ethical behavior in relation to the employment of such individuals. Individuals with psychiatric disabilities often evoke negative reactions from those in their environment. Lastly, we provide recommendations for how employees and (...) organizations can become more proactive in providing individuals with such disabilities equal employment opportunities for both access and accommodation in the workplace. (shrink)
The authors discuss some of the conceptual issues that must be considered in using and understanding psychiatric classification. DSM-IV is a practical and common sense nosology of psychiatric disorders that is intended to improve communication in clinical practice and in research studies. DSM-IV has no philosophic pretensions but does raise many philosphical questions. This paper describes the development of DSM-IV and the way in which it addresses a number of philosophic issues: nominalism vs. realism, epistemology in science, (...) the mind/body dichotomy, the definition of mental disorders, and dimensional vs. categorical classification. Keywords: DSM-IV, Nosology, psychiatric classification CiteULike Connotea Del.icio.us What's this? (shrink)
Executive function has become an important concept in explanations of psychiatric disorders, but we currently lack comprehensive models of normal executive function and of its malfunctions. Here we illustrate how defeasible logical analysis can aid progress in this area. We illustrate using autism and attention deficit hyperactivity disorder (ADHD) as example disorders, and show how logical analysis reveals commonalities between linguistic and non-linguistic behaviours within each disorder, and how contrasting sub-components of executive function are involved across disorders. This analysis (...) reveals how logical analysis is as applicable to fast, automatic and unconscious reasoning as it is to slow deliberate cogitation. (shrink)
This paper will consider the right not to know in the context of psychiatric disorders. It will outline the arguments for and against acquiring knowledge about the results of genetic testing for conditions such as breast cancer and Huntington’s disease, and examine whether similar considerations apply to disclosing to clients the results of genetic testing for psychiatric disorders such as depression and Alzheimer’s disease. The right not to know will also be examined in the context of the diagnosis (...) of psychiatric disorders that are associated with stigma or for which there is no effective treatment. (shrink)
Psychiatric research is advancing rapidly, with studies revealing new investigative tools and technologies that are aimed at improving the treatment and care of patients with psychiatric disorders. However, the ethical framework in which such research is conducted is not as well developed as we might expect. In this paper we argue that more thought needs to be given to the principles that underpin research in psychiatry and to the problems associated with putting those principles into practice. In particular, (...) we comment on some of the difficulties posed by the twin imperatives of ensuring that we respect the autonomy and interests of the research subject and, at the same time, enable potentially beneficial psychiatric research to flourish. We do not purport to offer a blueprint for the future; we do, however, seek to advance the debate by identifying some of the key questions to which better answers are required. (shrink)
The following theses are defended in this paper: (1) The concept of autonomous action is centrally relevant to understanding numerous psychiatric conditions, namely, conditions that subvert autonomy; (2) The details of an analysis of autonomous action matter; a vague or rough characterization is less illuminating; (3) A promising analysis for this purpose (and generally) is a version of the "multi-tier model". After opening with five vignettes, I begin the discussion by highlighting strengths and weaknesses of contributions by other authors (...) who examine the relationship between autonomy and autonomysubverting psychiatric conditions. I then present an analysis of the concept of autonomous action, before employing this analysis in a suggestive exploration of the conditions illustrated in the vignettes. Keywords: autonomy, multi-tier model, psychiatric conditions CiteULike Connotea Del.icio.us What's this? (shrink)
This paper provides an interpretation, based on the social systems theory of German sociologist Niklas Luhmann, of the recent paradigmatic shift of mental health care from an asylum-based model to a community-oriented network of services. The observed shift is described as the development of psychiatry as a function system of modern society and whose operative goal has moved from the medical and social management of a lower and marginalized group to the specialized medical and psychological care of the whole population. (...) From this theoretical viewpoint, the wider deployment of the modern social order as a functionally differentiated system may be considered to be a consistent driving force for this process; it has made asylum psychiatry overly incompatible with prevailing social values (particularly with the normative and regulative principle of inclusion of all individuals in the different functional spheres of society and with the common patterns of participation in modern function systems) and has, in turn, required the availability of psychiatric care for a growing number of individuals. After presenting this account, some major challenges for the future of mental health care provision, such as the overburdening of services or the overt exclusion of a significant group of potential users, are identified and briefly discussed. (shrink)
A recent literature review of commentaries and ‘state of the art’ articles from researchers in psychiatric genetics (PMG) offers a consensus about progress in the science of genetics, disappointments in the discovery of new and effective treatments, and a general optimism about the future of the field. I argue that optimism for the field of psychiatric molecular genetics (PMG) is overwrought, and consider progress in the field in reference to a sample estimate of US National Institute of Mental (...) Health funding for this paradigm for the years 2008 and 2009. I conclude that the amounts of financial investment in PMG is questionable from an ethical perspective, given other research and clinical needs in the USA. (shrink)
The author examines the existential, historical, and political roots of psychiatric power, locating them, respectively, in the universality of guilt feelings and the desire to escape them, in psychiatry (replacing religion) as an institution offering surcease from such (and similar disturbing) feelings, and in the alliance, in modern societies, between psychiatry and the state. Clinical psychiatry and psychoanalysis, each in its own distinctive way, have served to legitimize the uses of psychiatric power. Liberty from coercive psychiatry requires destroying (...) the legitimacy, and hence power, of coercive psychiatric principles and practices. (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)
Flaws, biases, and ethical problems surrounding research and diagnosis may lead to inappropriate or inequitable treatments that exacerbate or fail to improve the misery that some individuals face due to their psychiatric conditions. Possible androcentric biases in the choice and definition of categories for diagnosis available in DSM-III-R may in turn influence the approaches of therapists to clients, particularly male therapists towards female clients. Androcentric bias in diagnosis, which may also be reflected in the values of the psychiatrist, may (...) lead to treatment regimens designed to make clients fit into roles, positions, and norms prescribed by a culture reflecting patriarchal values. Some acceptance of attempts by feminists to correct androcentrism are beginning to emerge in psychiatric diagnosis. Keywords: androcentrism, bias, feminist, psychiatry of biology CiteULike Connotea Del.icio.us What's this? (shrink)
DSM-III and its revisions have provided little in the way of explicit historical or philosophical foundations. The logical empiricism embedded in its operational criteria and its external approach to validation are inadequate to account for the presumption of nosological regularities or the specific categories endorsed by the taxonomy. The nosologic operation that Jaspers referred to as the "synthesis of disease entities" is explored in connection with the central distinction in DSM-IV between mood disorders and schizophrenic disorders. This synthetic operation is (...) analyzed in terms of the paradigmatic shift from the mania-melancholia matrix of pre-modern psychiatry to the manic-depression/dementia praecox model defined by the work of Kraepelin. In the context of this analysis the self-evidence of these regularities is questioned. Keywords: DSM-III, DSM-IV, mood disorders, nosology, schizophrenic disorders CiteULike Connotea Del.icio.us What's this? (shrink)
The AIDS epidemic calls for an ethical analysis of conflicting obligations surrounding HIV-infected psychiatric patients and confidentiality, as well as issues that go beyond confidentiality. Although laws pertaining to HIV infection have been enacted in a number of states, these statutes leave much discretion to health professionals. The ethical principle known as "the harm principle" can permit disclosure of confidential information and detention or isolation of psychiatric patients who pose a threat of infecting other patients. From an ethical (...) point of view, however, the circumstances under which traditional protections may be weakened or abandoned remain limited. (shrink)
Currently, there is a growing interest in combining genetic information with physiological data measured by functional neuroimaging to investigate the underpinnings of psychiatric disorders. The first part of this paper describes this trend and provides some reflections on its chances and limitations. In the second part, a thought experiment using a commonsense definition of psychiatric disorders is invoked in order to show how information from this kind of research could be used and potentially abused to invent new mental (...) illnesses. It is then argued why an inference to the best explanation could provide an antidote to such attempts. The conclusion emphasises why normative criteria, such as those used to define disorders, cannot be derived from descriptive empirical results alone. While the etiology of some psychiatric diseases may be purely organic, there are many other cases where the psychiatric symptoms and the associated genotypes and phenotypes have an essentially and irreducibly external meaning that is derived from social and political factors. A limited perspective on the genes and brain of man carries the risk that psychiatry may increasingly treat the effects of other domains, although social and political solutions would be more appropriate. (shrink)
Many of Rose's criticisms of determinism in biology have clear relevance to modern cognitive and psychiatric science; too narrow a focus on the brain as an information processing machine runs the risk of neglecting the context in which information processing takes place, and too narrow a focus on the neuroscience of psychopathology runs the risk of neglecting other levels of explanation for these phenomena. It should be emphasized, however, that animal and genetic studies of phenomena of interest to cognitive (...) and psychiatric science (e.g., Alzheimer's disorder, schizophrenia, attention deficit/hyperactivity disorder, and violence), while perhaps only providing a partial perspective, may be useful in understanding these phenomena and in leading to appropriate psychiatric interventions. (shrink)
Given that visualisations via medical imaging have tremendously increased over the last decades, the overall presence of colour-coded brain slices generated on the basis of functional imaging, i.e. neuroimaging techniques, have led to the assumption of so-called kinds of brains or cognitive profiles that might be especially related to non-healthy humans affected by neurological, neuropsychological or psychiatric syndromes or disorders. In clinical contexts especially, one must consider that visualisations through medical imaging are suggestive in a twofold way. Imaging data (...) not only visually render pathological entities, but also tend to represent objective and concrete evidence for these psychophysical states in question. This article aims to identify key issues in visually rendering psychiatric disorders via functional approaches of imaging within the neurosciences from an epistemological point of view. (shrink)
Epistemology — the study of knowledge — is a philosophical discipline with close ties to psychiatry. When epistemologists address specific questions about how knowledge is actually realized by human beings, their philosophy must be informed by empirical studies of the sort psychiatrists now take up in a variety of forms. As this paper describes, psychiatrists can likewise improve their understanding of human psychology through a deeper appreciation of philosophical analysis in epistemology.The aim of this article is to introduce a unifying (...) framework within which the experience from different approaches to psychiatry — (1) the conceptual schemas of cognitive psychiatry, (2) the mental structures of psychoanalytic psychiatry, (3) the categorical forms of existential psychiatry, and (4) the neural pathways of biological psychiatry — can all be applied productively to the central question of epistemology. By establishing a broad understanding of the problem of knowledge, this new view of epistemology is developed within the idiom of each psychiatric approach. In addressing themselves to a unitary problem, these diverse psychiatric approaches are themselves revealed, not as competing points of view, but as complementary views of a single subject. The result is a new epistemology that can not only bring the insights of psychiatry to philosophy, but can also contribute to the care of patients when psychiatrists bring this broader view to their clinical work. (shrink)
The aim of this contribution is to provide a few historical and conceptual insights on the question of the impact of current developments in the neurosciences on the concept of psychiatric disease. Alzheimerâs disease is a good example when considering this important question. On the one hand, Alzheimerâs disease has a somewhat ambiguous status in terms of disorders affecting the mind or the psyche. This ambiguous status is illustrated by the fact that one commonly qualifies Alzheimerâs disease as a (...) âneuropsychiatricâ disorder, because it cannot easily be classified as either a âneurologicalâ or âpsychiatricâ disorder. On the other hand, the concept of Alzheimerâs disease was created at the beginning of the twentieth century, as the neurosciences were beginning to take shape themselves as scientific disciplines. To compare Alzheimerâs original ideas with current conceptions may thus help us to precisely specify current developments in the neurosciences. (shrink)
In the May, 1960, issue of the American Bar Association Journal (vol. 499), Morton Birnbaum, a lawyer and physician, argued for a legal right to psychiatric treatment of the involuntarily committed mentally ill person. In the 18 years since his article appeared,, there have been several key court cases in which this concept of a right to psychiatric treatment has figured prominently and decisively. It is important to note that the language of the decisions have had at least (...) an indirect effect in the recently enacted mental Hygiene Law of the State of New York. While I shall not seek to establish the historical thesis that Birnbaum’s article has been efficacious in bringing about both these court decisions and changes in statutory laws, I do want to examine Birnbaum’s article and some of the opinions for three cases: Wyatt v. Stickney (1972), Wyatt v. Aderholt (1974), and O’Connor v. Donaldson (422 US 563, 1975), in an effort to understand both the significance of these changes in our laws and the underlying philosophical and ethical notions of which they are an expression. Birnbaum observed that the notable feature of the legal situation at the time was that there had not been recognized a constitutional requirement that one who had been institutionalized for mental illness according to due process must receive treatment. Birnbaum argued that the effects of an omission of such a requirement to treat were that mental institutions typically offered only custodial care, that patients who were held only under custodial care typically did not improve, and that the result was that involuntary incarceration in a mental institution was, at least from the point of view of the patient, functionally no different than would be imprisonment for an unspecified period of time. Birnbaum argued for a recognition and enforcement in the courts of the right to treatment “...as a necessary and overdue development of our present concept of due process of law,” i.e., as required by the 14th Amendment to the U.S.. (shrink)
Psychiatrists are frequently called upon to make assessments of the rationality or irrationality of persons for a variety of medical-legal purposes. A key category is that of evaluations of a patient's capacity to grant informed consent for a medical procedure. A diagnosis of mental illness is neither a necessary nor a sufficient condition for a finding of incompetence. The notion of competency to grant consent, which is a mixed psychiatric-legal concept, shares some features with philosophical conceptions of rationality, but (...) differs from them in a number of important respects. This article describes the actual practice of psychiatrists when making such judgments, along with the standards of competency they employ. A comparison is made between those notions of competency and predominant philosophical conceptions of rationality. (shrink)
Depue & Morrone-Strupinsky's (D&M-S's) model of affiliation meets the criteria advanced for the definition of behavior systems and endophenotypes. We argue that its application in psychiatry could be useful for identifying a biological pathophysiology common to a variety of conditions that are currently classified in very different categories of psychiatric nosography, including autism, schizoid personality, primary psychopathy, and dismissing attachment.
The same aggressive act will – all else being equal – have a different behavioral significance according to whether it is performed by a man or a woman. Such a perspective should have profound implications for legal and psychiatric practice, and for social policy in general.
There is a spectrum of child psychiatric and neurological disorders, in all of which a comorbidity with obsessive-compulsive disorder and ritualized behavior is very common. Therefore, they may appear as a basis for the rituals in children that cross into adolescence and adulthood. Resolving the nature of these disorders may help us to better understand “Why ritualized behavior?” (Published Online February 8 2007).
Using as a guide Pellegrino and Thomasma's end-oriented beneficence model of the virtues in medical practice, the author derives from the cardinal forms of psychiatric treatment a set of virtues particular to this field. Prior work from Jung, Havens and Menzer-Benaron helps to clarify the analysis.
Psychiatric Medicine has been accused justly of making its diagnoses on the patient's report of symptoms and the physician's subjective observations of the patient. The main problem has been the lack of reliable data compounded by the stigma of a mental diagnosis. More recently, third-party pressures have become an added threat to objectivity. New knowledge of brain function, especially neurotransmitters, and more specific and effective medication have made the need for accurate diagnoses more acute. Psychiatry has responded by frequent (...) and often controversial changes in its diagnostic criteria. Much of the controversy stems from a lack of accurate measurements to validate the diagnoses, thereby allowing for differences of opinion of a highly subjective nature. The problem is complicated by the chronic, but irrational, belief that there is a separation between mental and somatic illness. Keywords: calibration, diagnoses, objective vs. subjective, stigma, third-party CiteULike Connotea Del.icio.us What's this? (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 this paper, I explore the links between liberal political theory and the evaluative nature of medical classification, arguing for stronger recognition of those links in a liberal model of medical practice. All judgments of medical or psychiatric "dysfunction," I argue, are fundamentally evaluative, reflecting our collective willingness or reluctance to tolerate and/or accommodate the conditions in question. Illness, then, is "socially constructed." But the relativist worries that this loaded phrase evokes are unfounded; patients, doctors, and communities will agree (...) in the vast majority of cases about what counts as illness. Where they cannot come to agreement, however, we are faced with precisely the sort of dispute about values and ways of life that the institutions of the liberal state are designed to accommodate. I accordingly sketch a model of medical practice, based loosely on Jürgen Habermas's political theories, designed to maximize both our awareness and our understanding of these disputes. (shrink)
IntroductionCultural Consultation is a clinical process that emerged from anthropological critiques of mental healthcare. It includes attention to therapeutic communication, research observations and research methods that capture cultural practices and narratives in mental healthcare. This essay describes the work of a Cultural Consultation Service (ToCCS) that improves service user outcomes by offering cultural consultation to mental health practitioners. The setting is a psychiatric service with complex and challenging work located in an ethnically diverse inner city urban area. Following a (...) period of 18 months of cultural consultation, we gather the dominant narratives that emerged during our evaluation of our service. Results: These narratives highlight how culture is conceptualized and acted upon in the day-to-day practices of individual health and social care professionals, specialist psychiatric teams and in care systems. The findings reveal common narratives and themes about culture, ethnicity, race and their perceived place and meaningfulness in clinical care. These narratives express underlying assumptions and covert rules for managing, and sometimes negating, dilemmas and difficulties when considering “culture” in the presentation and expression of mental distress. The narratives reveal an overall “culture of understanding cultural issues” and specific “cultures of care”. These emerged as necessary foci of intervention to improve service user outcomes. Conclusion: Understanding the cultures of care showed that clinical and managerial over-structuring of care prioritises organisational proficiency, but it leads to inflexibility. Consequently, the care provided is less personalised and less accommodating of cultural issues, therefore, professionals are unable to see or consider cultural influences in recovery. (shrink)
This paper focuses on one of the original moments of the development of the “phenomenological” current of psychiatry, namely, the psychopathological research of Ludwig Binswanger. By means of the clinical and conceptual problem of schizophrenia as it was conceived and developed at the beginning of the twentieth century, I will try to outline and analyze Binswanger’s perspective from a both historical and epistemological point of view. Binswanger’s own way means of approaching and conceiving schizophrenia within the scientific, medical, and (...) class='Hi'>psychiatric context of that time will lead us to grasp the epistemological stakes at the origins of his project of reforming psychiatry by means of phenomenology. I will finally attempt to upgrade and update Binswanger’s project in light of the current reappraisal of phenomenology within the ongoing debate on psychopathology engaged by studies in the field of science and philosophy of mind. (shrink)
Background: Adherence to ethical principles in clinical research and practice is becoming topical issue inChina, where the prevalence of mental illness is rising, but treatment facilities remainunderdeveloped. This paper reports on a study aiming to understand the ethical knowledgeand attitudes of Chinese mental health professionals in relation to the process of diagnosisand treatment, informed consent, and privacy protection in clinical trials. Methods: A self-administered survey was completed by 1110 medical staff recruited from Shanghai's22 psychiatric hospitals. Simple random selection methods (...) were used to identify targetindividuals from the computerized registry of staff. Results: The final sample for analysis consisted 1094 medical staff (including 523 doctors, 542nurses, 8 pharmacologists and 21 other staff). The majority reported that their medicalinstitutions had not established an Ethics Committee (87.8%) and agreed that EthicsCommittees should be set up in their institutions (72.9%). Approximately half (52%) had notreceived systematic education in ethics, and almost all (89.1%) of the staff thought it wasnecessary. Nearly all participants (90.0%) knew the Shanghai Mental Health Regulationswhich was the first local regulations relating to mental health in China, but only 11% and16.6% respectively knew of the Nuremberg Code and the Declaration of Helsinki. About half(51.8%) thought that the guardian should make the decision as to whether the patientparticipated in clinical trials or not. Conclusions: The study indicates that most psychiatric hospitals in Shanghai have no Medical EthicsCommittee. More than half the medical staff had not received systematic education andtraining in medical ethics and they have insufficient knowledge of the ethical issues related toclinical practice and trials. Training in ethics is recommended for medical staff during theirtraining and as ongoing professional development. (shrink)
The impact of current developments in the neurosciences on the concept of psychiatric diseases Content Type Journal Article DOI 10.1007/s10202-008-0054-2 Authors Felix Thiele, Europäische Akademie zur Erforschung von Folgen wissenschaftlich-technischer Entwicklungen Bad Neuenahr-Ahrweiler GmbH Bad Neuenahr-Ahrweiler Germany Barbara Hawellek, Universität Bonn Klinik für Psychiatrie und Psychotherapie Bonn Germany Journal Poiesis & Praxis: International Journal of Technology Assessment and Ethics of Science Online ISSN 1615-6617 Print ISSN 1615-6609 Journal Volume Volume 6 Journal Issue Volume 6, Numbers 1-2.
In this new addition to the Collège de France lecture series, Michel Foucault's historical enquiry into the uses and techniques of power and knowledge finds itself directed towards a study of the birth of psychiatry. Psychiatric Power shows not only how Western society's division of the "mad" from the "sane" began, but also how society, medicine, and law and their treatment of the "mad" developed into what we now recognize as modern psychiatry, and how modern social and political attitudes (...) towards madness developed. A seminal work by this leading thinker of the modern age, Psychiatric Power builds on Foucault's published writings while opening new vistas within historical and philosophical study. (shrink)
Applying a necessary condition communication theory formalism roughly similar to that of Dretske, but focused entirely on the statistical properties of long sequences of signals emitted by the interacting cognitive modules of human biology, we explore the regularities apparent in comorbid psychiatric and chronic physical disorders using an extension of recent perspectives on autoimmune disease. We find that structured psychosocial stress can literally write a distorted image of itself onto child development, resulting in a life course trajectory to characteristic (...) forms of comorbid mind/body dysfunction affecting both dominant and subordinate populations within a pathogenic social hierarchy. (shrink)
Current symptom-based DSM and ICD diagnostic criteria for mental disorders are prone to yielding false positives because they ignore the context of symptoms. This is often seen as a benign flaw because problems of living and emotional suffering, even if not true disorders, may benefit from support and treatment. However, diagnosis of a disorder in our society has many ramifications not only for treatment choice but for broader social reactions to the diagnosed individual. In particular, mental disorders impose a sick (...) role on individuals and place a burden upon them to change; thus, disorders decrease the level of respect and acceptance generally accorded to those with even annoying normal variations in traits and features. Thus, minimizing false positives is important to a pluralistic society. The harmful dysfunction analysis of disorder is used to diagnose the sources of likely false positives, and propose potential remedies to the current weaknesses in the validity of diagnostic criteria. (shrink)
Medical professionals, including mental health professionals, largely agree that moral judgment should be kept out of clinical settings. The rationale is simple: moral judgment has the capacity to impair clinical judgment in ways that could harm the patient. However, when the patient is suffering from a "Cluster B" personality disorder, keeping moral judgment out of the clinic might appear impossible, not only in practice but also in theory. For the diagnostic criteria associated with these particular disorders (Antisocial, Borderline, Histrionic, Narcissistic) (...) are expressed in overtly moral language. I consider three proposals for dealing with this problem. The first is to eliminate the Cluster B disorders from the DSM on the grounds that they are moral, rather than mental, disorders. The second is to replace the morally laden language of the diagnostic criteria with morally neutral language. The third is to disambiguate the notion of moral judgment so as to respect the distinction between having morally disvalued traits and having moral responsibility for those traits. Sensitivity to this distinction enables the clinician, at least in theory, to employ morally laden diagnostic criteria without adopting the sort of morally judgmental (and potentially harmful) attitude that results from the tacit presumption of moral responsibility. I argue against the first two proposals and in favor of the third. In doing so, I appeal to Grice's distinction between conventional and conversational implicature. I close with a few brief remarks on the irony of retaining overtly moral language in an ostensibly medical manual for the diagnosis of mental disorders. (shrink)
The McNaughton rules for determining whether a person can be successfully defended on the grounds of mental incompetence were determined by a committee of the House of Lords in 1843. They arose as a consequence of the trial of Daniel McNaughton for the killing of Prime Minister Sir Robert Peel’s secretary. In retrospect it is clear that McNaughton suffered from schizophrenia. The successful defence of McNaughton on the grounds of mental incompetence by his advocate Sir Alexander Cockburn involved a profound (...) shift in the criteria for such a defence, and was largely based on the then recently published scientific thesis of the great US psychiatrist Isaac Ray, entitled A Treatise on the Medical Jurisprudence of Insanity. Subsequent discussion of this defence in the House of Lords led to the McNaughton rules, still the basis of the defence of mental incompetence in the courts of much of the English-speaking world. This essay considers one of these rules in the light of the discoveries of cognitive neuroscience made during the 160 years since Ray’s treatise. A major consideration is the relationship between the power of self-control and irresistible impulse as conceived by Cockburn on the one hand, and by cognitive neuroscience on the other. The essay concludes with an analysis of the notion of free will and of the extent to which a subject can exert restraint in the absence of particular synaptic connections in the brain. (shrink)
This paper explores the factors that contribute to the degree of a mood disorder patient’s self- insight, defined here as her understanding of the particular contingencies of her life that are responsive to her personal identity, interpersonal relationships, illness symptoms, and the relationship between these three necessary components of her lived experience. I consider three factors: (i) the Diagnostic Statistical Manual of Mental Disorders (DSM), (ii) the DSM culture, and (iii) the cognitive architecture of the self. I argue that the (...) symptom-based descriptions of mood disorders which eliminate the subjective features of the patient’s illness experience, in conjunction with the features of the DSM-culture and the cognitive biases that guide the patient, contribute to the impoverishment of her self-insight. The resulting impoverished self-insight would prevent her from developing resourceful responses to her interpersonal problems. In analyzing how these factors combine to influence the patient’s self-insight, I distinguish the therapeutic impact of receiving a psychiatric diagnosis, which facilitates patient’s clinical treatment, from its reflective impact, how the diagnosis informs the patient’s reflection on who she is, how her mental disorder is expressed, and how her interpersonal relationships proceed. I substantiate my argument by considering a patient’s memoir of psychopathology. (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.
From his earliest published work, Mental Illness and Personality (1954), to his last project, The History of Sexuality , Foucault was critical of the human sciences as a dubious and dangerous attempt to model a science of human beings on the natural sciences. He therefore preferred existential therapy, which did not attempt to give a causal account of human nature, but rather described the general structure of the human way of being and its possible distortions. Foucault focused his attack on (...) psychiatry, which claimed to have an explanation of normal and abnormal functioning of the personality modeled on medicine. Freud typified for him this deep mistake which he traced first to the Kantian understanding of human beings as transcendental/ empirical doubles which must think their own unthought, and then later to the gradually developing confessional practices which lead people in our culture to try unsuccessfully to put all their desires into words so as to conform to the norms of psychoanalysis which in turn are based on an account of sexuality as a cause of personality. Foucault proposed his genealogical account of how our culture arrived at this view of man as sexual being as a form of therapy which was to help us free ourselves from this restrictive self- interpretation. Keywords: normal, mental illness, sexuality, psychoanalysis CiteULike Connotea Del.icio.us What's this? (shrink)
In “Mad Narratives: Self-Constitutions Through the Diagnostic Looking Glass,” by using narrative approaches to the self, I explore how the diagnosis of mental disorder shapes personal identities and influences flourishing. My particular focus is the diagnosis grounded on the criteria provided by the Diagnostic Statistical Manual of Mental Disorders (DSM). I develop two connected accounts pertaining to the self and mental disorder. I use the memoirs and personal stories written by the subjects with a DSM diagnosis as illustrations to bolster (...) my claims. First, expanding on the narrative approaches to the self, I explain how narratives about a subject shape her self-constitution. I elucidate how this process is generated by drawing on research in developmental psychology, cognitive science, and social psychology. Next, using this account as a springboard, I argue that the DSM diagnosis of mental disorder serves as a source of narrative, entering into the patients’ autobiographical and social narratives. This plays an important role in the diagnosed subjects’ self-understanding, self-constitution and flourishing. In this vein, how mental disorders are classified is not only a theoretical question about accurately taxonomizing the various experiences related to mental distress but also an ethical question about which ways of talking about mental disorders will allow subjects to respond effectively to their psychological distress, to flourish and to live autonomous and fulfilling lives. Finally, I suggest that the DSM-based narratives wield a double-edged sword when it comes to the subject’s flourishing: On the one hand, there are problems with some DSM-based narratives that stem from the DSM diagnostic schema and the culture of DSM diagnoses. These problems render these DSM-based narratives unbeneficial for flourishing as they constrain the range of adoptive social, cognitive and emotional responses the subjects can give to their mental disorders. On the other hand, there are grounds to believe that some DSM-based narratives help subjects to flourish. For instance, they provide certainty to subjects' otherwise puzzling symptoms and help them reach out to others with similar experiences. Understanding how the DSM-based narratives can both benefit and harm will help us address problems with psychiatric diagnoses and the dissemination of knowledge about mental disorders in popular culture. The project aims to convince both philosophers and psychiatrists that no plausible theory of the self can be developed without attending to the topic of mental disorder and that no theory of mental disorder can be complete without devising the tools provided by the philosophical approaches to the self as well as developmental and social psychology. It also calls for methodological alterations in mental health ethics research, arguing that a careful scrutiny of mental disorder memoirs can advance the ethical underpinnings to the practice of psychiatry. (shrink)
Psychiatry presents a unique array of difficult ethical questions. However, a major challenge is to approach psychiatry in a way that does justice to the real ethical issues. Recently there has been a growing body of research in empirical psychiatric ethics, and an increased interest in how empirical and philosophical methods can be combined. Empirical Ethics in Psychiatry demonstrates how ethics can engage more closely with the reality of psychiatric practice and shows how empirical methodologies from the social (...) sciences can help foster this link. -/- The book is divided into two sections. In the first section there are discussions of the possibility of empirical ethics from a theoretical standpoint and an overview of the history of empirical medical ethics in general. The second, larger section is made up of chapters, discussing specific research projects in empirical psychiatric ethics. The contributors reflect on their choice of method: how and why they combine empirical and philosophical work, and how the two approaches relate to each other. The chapters in the second part thus have two purposes. The first is to present examples of empirical ethics in psychiatry; the second is to reflect on the way in which empirical research can support ethical analysis. -/- Empirical Ethics in Psychiatry is a unique contribution to bioethics and will be fascinating reading for all those working within the field, as well as mental health care professionals. (shrink)
Fielding and Marwede attempt to lay down directions for an applied onto-psychiatry. According to their proposal, such an enterprise requires us to accept certain metaphysical and methodological claims about how brain and experience are related. To put it in one sentence, our critique is that we find their metaphysics questionable and their methodology clinically impracticable.A first fundamental problem for their project, as it is expressed in their paper, is that their overall aim is unclear. At least three different aims might (...) be read as motivating their efforts, here listed according to their strength:They aim to develop tools for the development of knowledge representational systems that can be used by .. (shrink)
At this point in time, it is hard to say which consequences for the concept of mental illness result from modern genetics. Current research projects are trying to find significant statistical correlations between the diagnosis of a disease and a gene locus or an endophenotype. Up until now, there has not been any identification of alleles or mutations causing mental illness. In the meantime, the relations between the genetic basis and the disease are given the term genetic vulnerability as a (...) placeholder; this concept simplifies the complex relations between the DNA and even the simplest cell functions observed in modern genetics. According to complex gene models like the systemic theory of DNA, it will not be possible to identify the genetic factors without a precise knowledge of the factors which modulate the gene expression. The significance of genetics as part of the concept of mental illness will not be able to be defined without further progress in developmental biology and psychology. Currently, psychological theory fails to acknowledge the complexity of the relationship between the DNA and the environment. Some starting points from which to develop such an understanding can be received from developmental studies and studies of the psychophylogenesis . An interdisciplinary concept of the biological basis of the psyche is needed. (shrink)