Nosology

Cardiac disease is the leading cause of death worldwide. Cardiovascular diseases can be prevented if an effective diagnostic is made at the initial stages. The ECG test is referred to as the diagnostic assistant tool for screening of cardiac disorder. The research purposes of a cardiac disorder detection system from 12-lead-based ECG Images. The healthcare institutes used various ECG equipment that present results in nonuniform formats of ECG images. The research study proposes a generalized methodology to process all formats of (...) ECG. Single Shoot Detection MobileNet v2-based Deep Neural Network architecture was used to detect cardiovascular disease detection. The study focused on detecting the four major cardiac abnormalities with 98% accuracy results were calculated. The work is relatively rare based on their dataset; a collection of 11,148 standard 12-lead-based ECG images used in this study were manually collected from health care institutes and annotated by the domain experts. The study achieved high accuracy results to differentiate and detect four major cardiac abnormalities. Several cardiologists manually verified the proposed system’s accuracy result and recommended that the proposed system can be used to screen for a cardiac disorder. (shrink)

This article addresses the issues related to the problem of classification of mental disorders in psychiatry in the context of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. First, some background information is provided on the history of the classification of mental disorders and the evolution that DSM has had over time is shown. Secondly, the delimitation of the normal and the pathological in psychiatry is investigated through Canguilhem's medical-philosophical thought. Thirdly, the biopolitical management of psychic (...) sufferings is reflected in the diagnostic criteria of the DSM-V and its increasing medicalization. Finally, an approach to the concepts of health and disease in Canguilhem is made as it incorporates existential and experiential variables absent in the DSM-V classifications and in the psychiatric diagnosis. (shrink)

This paper addresses the role of categories and dimensions in the classification of psychopathology. While psychopathology does not sort itself out neatly into natural categories, we do find rough, symptom-based groupings that, through refinement, become diagnostic categories. Given that these categories suffer from comorbidity, uncertain boundaries, and excessive “unspecified disorder” diagnoses, there has been a move toward refining the diagnoses with dimensional measures. The paper traces efforts both to improve the diagnostic categories with validators that allow at least partial validity (...) and to introduce dimensional measures into the diagnostic manual. Drawing from the philosophical pragmatism of Charles Sanders Peirce, William James, and John Dewey, which emphasizes the practical, effect-sensitive consequences of a theory along with an emphasis on empirical evidence and the progressive, probabilistic character of knowledge, the paper argues that these efforts must be guided both by scientific validity and clinical utility. (shrink)

Contemporary psychiatry finds itself in the midst of a crisis of classification. The developments begun in the 1980s—with the third edition of the Diagnostic and Statistical Manual of Mental Disorders —successfully increased inter-rater reliability. However, these developments have done little to increase the predictive validity of our categories of disorder. A diagnosis based on DSM categories and criteria often fails to accurately anticipate course of illness or treatment response. In addition, there is little evidence that the DSM categories link up (...) with genetic findings, and even less evidence that they... (shrink)

Cancer—and scientific research on cancer—raises a variety of compelling philosophical questions. This entry will focus on four topics, which philosophers of science have begun to explore and debate. First, scientific classifications of cancer have as yet failed to yield a unified taxonomy. There is a diversity of classificatory schemes for cancer, and while some are hierarchical, others appear to be “cross-cutting,” or non-nested. This literature thus raises a variety of questions about the nature of the disease and disease classification. Second, (...) philosophers of science have historically taken the aim of science to be arriving at true theories. However, scientists studying cancer come from a variety of disciplines, with different scientific as well as practical aims. Perhaps it is not surprising, then, that historians and philosophers of science do not seem to agree on how best to characterize the aim and structure of cancer research; it is far from clear whether the appropriate characterization of the aim is arriving at true theories, or even whether the proper units of analysis are “theories”, or instead, “models”, “explanatory frameworks”, “research programs”, “paradigms”, or perhaps, “experimental traditions”. With the rise of “big data” science—such as the Cancer Genome Atlas Project (or TCGA)—and “systems” approaches to the study of disease, both philosophers and historians of science are rethinking how best to describe and explain these distinctive kinds of scientific inquiry. -/- Third, cancer is in part a byproduct of our developmental and life history, as well as our evolutionary history. Cancer progression can be compared to a reversion of development, or, to the evolution of multicellularity. Thus, cancer raises intriguing questions about how we conceive of “functions”, “development”, and the role of our evolutionary history and particularly, selective trade-offs, in vulnerability to disease. -/- Last but not least, cancer research provides a case study for consideration of the roles of values at the science-policy interface. Epidemiological and toxicological research on cancer’s causes informs toxics law and regulatory policy, which raises a variety of questions about the nature of evidence and inductive risk in such contexts. (shrink)

Galen conceives of wounds, fractures, and similar conditions as belonging to one of the highest genera in his taxonomy of disease. This classification is puzzling, as much from an ancient Greco-Roman perspective as from a contemporary one. In what sense are wounds and other injuries diseases? The classification appears more perplexing in light of Galen's method of conceptual analysis, which takes ordinary language use as a starting point. What, then, motivated Galen's departure from common Greek conceptions of disease? This article (...) examines the class of disease that Galen called “dissolutions of continuity” in the broader context of his system of nosological definition and classification. It concludes that Galen's analysis of wounds is driven by his theory of causation, and by his localization of disease and its mechanism inside the body, a conceptualization typical of Greco-Roman medical writing. This conclusion sheds further light on Galen's method of disease classification and the role of dissolutions within it. (shrink)

Discussions of psychiatric nosology focus on a few popular examples of disorders, and on the validity of diagnostic criteria. Looking at Anorexia Nervosa, an example rarely mentioned in this literature, reveals a new problem: the DSM has a strict taxonomic structure, which assumes that disorders can only be located on one branch. This taxonomic assumption fails to fit the domain of psychopathology, resulting in obfuscation of cross-category connections. Poor outcomes for treatment of Anorexia may be due to it being pigeonholed (...) as an Eating Disorder, when a disturbance of body perception may be a more central symptom than food restriction. This paper explores the possibility of restructuring the DSM taxonomy to allow for a pluralist classification of disorders. This change could improve treatment and research without requiring any changes to diagnostic criteria. (shrink)

In psychiatry, many scientists desire to move from a classification system based on symptoms toward a system based on biological causes. The idea is that psychiatric diseases should be redefined such that each disease would be associated with specific biological causes. This desire is intelligible because causal disease models often facilitate understanding and identification of new ways to intervene in disease processes. In its attempt to move from syndromal to specific etiological definitions, psychiatry follows the trend of general medicine.Current psychiatric...

In this article, I will reconstruct the monocausal model and argue that modern 'multifactorial diseases' are not monocausal by definition. 'Multifactorial diseases' are instead defined according to a constitutive disease model. On closer analysis, infectious diseases are also defined using the constitutive model rather than the monocausal model. As a result, our classification models alone cannot explain why infectious diseases have a universal etiology while chronic and noncommunicable diseases lack one. The explanation is instead provided by the nineteenth-century germ theorists.

Nosology is the science of defining and classifying diseases. Meta‐nosology is the study of how we do this, on what principles nosological practices are based, the quality of the resulting medical taxonomy, and primarily whether/how diseases can be defined better than they are now. In modern Western medicine, there are a wide variety of ways in which diseases are defined and categorized. Examples include by the symptoms they present with (syndromic), their underlying causes (etiological), the biological mechanisms involved (pathogenetic), available (...) treatments, historical precedent, and through diagnostic exclusion. Here, I explore the hypothesis that how we define diseases has an impact on how (and how effectively) we research and treat them. I explore the philosophical implications of this thesis and suggest a direction that the underlying meta-physics of disease definition might follow. I conclude that further research is warranted into whether our current disease definitions could be improved upon. (shrink)

Some limitations of ‘category work’ in the history of psychiatry are illustrated via the example of attempts within US alienism and psychiatry since 1889 to identify psychosis and its prodromes. A slowly evolving acceptance of the need for specifiable biological disease concepts, distinct diagnostic categories and defined boundaries of the ‘before and after’ of psychosis among some elite physicians challenged widespread vernacular methods of diagnosis expressed as intuition, feelings or scent as well as local practices of creating novel placeholder terms (...) ‘as needed’ or using question marks to express liminality or confusion. When ‘error of diagnosis’ emerged as a concern circa 1909, the professional transformation of this ‘scientific self of subjectivity’ of the psychiatrist into a ‘scientific self of objectivity’ eventually resulted in the turn to numerical judgments based on rating scales for psychotic symptoms. However, rating scales do not ‘count’ anything at all and exist as instruments of liminality between subjective clinical opinion and the affection of objectivity that quantification symbolizes. (shrink)

This book explores a variety of conceptual and methodological questions about cancer and cancer research: Is cancer one disease, or many? If many, how many exactly? How is cancer classified? What does it mean, exactly, to say that cancer is “genetic,” or “familial”? What exactly are the causes of cancer, and how do scientists come to know about them? When do we have good reason to believe that this or that is a risk factor for cancer? How is cancer a (...) product or byproduct of multilevel evolution? Is cancer research unified? What sort of models, or theories, govern cancer research? This book takes a close look at these philosophical questions, by examining work in disciplines as diverse as cell and molecular biology, epidemiology, clinical medicine, and evolutionary biology. (shrink)

:Diagnostic classification systems in psychiatry have continued to rely on clinical phenomenology, despite limitations inherent in that approach. In view of these limitations and recent progress in neuroscience, the National Institute of Mental Health has initiated the Research Domain Criteria project to develop a more neuroscientifically based system of characterizing and classifying psychiatric disorders. The RDoC initiative aims to transform psychiatry into an integrative science of psychopathology in which mental illnesses will be defined as involving putative dysfunctions in neural nodes (...) and networks. However, conceptual, methodological, neuroethical, and social issues inherent in and/or derived from the use of RDoC need to be addressed before any attempt is made to implement their use in clinical psychiatry. This article describes current progress in RDoC; defines key technical, neuroethical, and social issues generated by RDoC adoption and use; and posits key questions that must be addressed and resolved if RDoC are to be employed for psychiatric diagnoses and therapeutics. Specifically, we posit that objectivization of complex mental phenomena may raise ethical questions about autonomy, the value of subjective experience, what constitutes normality, what constitutes a disorder, and what represents a treatment, enablement, and/or enhancement. Ethical issues may also arise from the use of biomarkers and phenotypes in predicting and treating mental disorders, and what such definitions, predictions, and interventions portend for concepts and views of sickness, criminality, professional competency, and social functioning. Given these issues, we offer that a preparatory neuroethical framework is required to define and guide the ways in which RDoC-oriented research can—and arguably should—be utilized in clinical psychiatry, and perhaps more broadly, in the social sphere. (shrink)

In psychiatry there is no sharp boundary between the normal and the pathological. Although clear cases abound, it is often indeterminate whether a particular condition does or does not qualify as a mental disorder. For example, definitions of ‘subthreshold disorders’ and of the ‘prodromal stages’ of diseases are notoriously contentious. -/- Philosophers and linguists call concepts that lack sharp boundaries, and thus admit of borderline cases, ‘vague’. Although blurred boundaries between the normal and the pathological are a recurrent theme in (...) many publications concerned with the classification of mental disorders, systematic approaches that take into account philosophical reflections on vagueness are rare. This book provides interdisciplinary discussions about vagueness in psychiatry by bringing together scholars from psychiatry, psychology, philosophy, history, and law. It draws together various lines of inquiry into the nature of gradations between mental health and disease and discusses the individual and societal consequences of dealing with blurred boundaries in medical practice, forensic psychiatry, and beyond. -/- Part I starts with an overview chapter that helps readers to navigate through the philosophy of vagueness and through the various debates surrounding demarcation problems in the classification and diagnosis of mental illness. Part II encompasses historical and recent philosophical positions on gradualist approaches to health and disease. Part III approaches the vagueness of present psychiatric classification systems, and the debates concerning their revisions by scrutinizing controversial categories, such as posttraumatic stress disorder, and the difficulties of day-to-day diagnostic and therapeutic practice. Part IV finally focuses on social, moral, and legal implications that arise when being mentally ill is a matter of degree. (shrink)

Important philosophical work has gone into debunking thoroughly entrenched positivist notions that objective science proceeds in a value neutral manner. Dr. Tamara Kayali Browne's article "A Role for Philosophers, Sociologists, and Bioethicists in Revising the DSM" admirably takes the next step. Given the evaluative elements that permeate, in this case, the science of nosology—how do we deal responsibly with those evaluative elements? She correctly, in my opinion, concludes that dealing with evaluative issues responsibly is tantamount to dealing with them ethically. (...) But, as her concrete example of the ethics of premenstrual dysphoric disorder demonstrates, dealing with the ethics of the science of... (shrink)

As it emerged from philosophical analyses and cognitive research, most concepts exhibit typicality effects, and resist to the efforts of defining them in terms of necessary and sufficient conditions. This holds also in the case of many medical concepts. This is a problem for the design of computer science ontologies, since knowledge representation formalisms commonly adopted in this field (such as, in the first place, the Web Ontology Language - OWL) do not allow for the representation of concepts in terms (...) of typical traits. The need of representing concepts in terms of typical traits concerns almost every domain of real world knowledge, including medical domains. In particular, in this article we take into account the domain of mental disorders, starting from the DSM-5 descriptions of some specific disorders. We favour a hybrid approach to concept representation, in which ontology oriented formalisms are combined to a geometric representation of knowledge based on conceptual space. As a preliminary step to apply our proposal to mental disorder concepts, we started to develop an OWL ontology of the schizophrenia spectrum, which is as close as possible to the DSM-5 descriptions. (shrink)

Psychiatry widely assumes an internalist biomedical model of mental illness. I argue that many of psychiatry’s diagnostic categories involve an implicit commitment to constitutive externalism about mental illness. Some of these categories are socially externalist in nature.

BackgroundAlthough values have increasingly received attention in psychiatric literature over the last three decades, their role has been only partially acknowledged in psychiatric classification endeavors. The review process of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders received harsh criticism, and was even considered secretive by some authors. Also, it lacked an official discussion of values at play. In this perspective paper we briefly discuss the interplay of some values in the scientific and non-scientific debate around (...) one of the most debated DSM-5 category proposals, the Attenuated Psychosis Syndrome. Then, we point out some ethical consequences of a facts-plus-values perspective in psychiatric classification.DiscussionDifferent stakeholders participated in the APS-debate and for analytical purposes we divided them into four groups: researchers in the field of high-risk mental states; the DSM-5 Psychotic Disorders Work Group; patient, carers and advocacy groups; and external stakeholders, not related to the previous groups, but which also publicly expressed their opinions about APS inclusion in DSM-5. We found that each group differently stressed the role of values we examined in the APS-debate. These values were ethical, but also epistemic, political, economic and ontological. The prominence given to some values, and the lack of discussion about others, generated divergent positions among stakeholders in the debate.SummaryAs exemplified by the APS discussion, although medicine is primarily an ethical endeavor, values of different kinds that take part in it also shape to a large extent the profession. Thus, it may be strategic to openly discuss values at play in the elaboration of diagnostic tools and classificatory systems. This task, more than scientifically or politically significant, is ethically important. (shrink)

Abstract: At present, psychiatric disorders are characterized descriptively, as the standard within the scientific community for communication and, to a cer- tain extent, for diagnosis, is the DSM, now at its fifth edition. The main rea- sons for descriptivism are the aim of achieving reliability of diagnosis and improving communication in a situation of theoretical disagreement, and the Ignorance argument, which starts with acknowledgment of the relative fail- ure of the project of finding biomarkers for most mental disorders. Descrip- tivism (...) has also the advantage of capturing the phenomenology of mental dis- orders, which appears to be essential for diagnosis, though not exhaustive of the nature of the disease. I argue that if we rely on the distinction between conceptions (procedures of identification) and concepts (reference-fixing representations), which was introduced in the philosophical debate on the nature of concepts, we may understand a limited but valid role for descrip- tive characterizations, and reply to common objections addressed by those who advocate a theoretically informed approach to nosology. (shrink)

At present, psychiatric disorders are characterized descriptively, as the standard within the scientific community for communication and, to a certain extent, for diagnosis, is the DSM, now at its fifth edition. The main reasons for descriptivism are the aim of achieving reliability of diagnosis and improving communication in a situation of theoretical disagreement, and the Ignorance argument, which starts with acknowledgment of the relative failure of the project of finding biomarkers for most mental disorders. Descriptivism has also the advantage of (...) capturing the phenomenology of mental disorders, which appears to be essential for diagnosis, though not exhaustive of the nature of the disease. I argue that if we rely on the distinction between conceptions (procedures of identification) and concepts (reference-fixing representations), which was introduced in the philosophical debate on the nature of concepts, we may understand a limited but valid role for descriptive characterizations, and reply to common objections addressed by those who advocate a theoretically informed approach to nosology. (shrink)

Disease is everywhere. Everyone experiences disease, everyone knows somebody who is, or has been diseased, and disease-related stories hit the headlines on a regular basis. Many important issues in the philosophy of disease, however, have received remarkably little attention from philosophical thinkers. -/- This book examines a number of important debates in the philosophy of medicine, including 'what is disease?', and the roles and viability of concepts of causation, in clinical medicine and epidemiology. Where much of the existing literature targets (...) conceptual analyses of health and disease, this book provides the reader with an insight into these debates, and develops plausible alternative accounts. The author explores a range of related subjects, discussing a host of interesting philosophical questions within clinical medicine, pathology and epidemiology. In the second part of the book, the author examines the concepts of causation employed by clinicians and pathologists, how one should classify diseases, and whether the epidemiologist's models for inferring the causes of disease are all they're cracked up to be. (shrink)

What kind of knowledge is medical knowledge? Can medicine be explained scientifically? Is disease a scientific concept, or do explanations of disease depend on values? What is ‘evidence-based’ medicine? Are advances in neuroscience bringing us closer to a scientific understanding of the mind? The nature of medicine raises fundamental questions about explanation, causation, knowledge and ontology – questions that are central to philosophy as well as medicine. In this book Paul R. Thompson and Ross E. G. Upshur introduce the fundamental (...) issues in philosophy of medicine for those coming to the subject for the first time. They introduce and explain the following key topics: Understanding the physician-patient relationship: the phenomenology of the medical encounter. Models and theories in biology and medicine: what role do theories play in medicine? Are they similar to scientific theories? Randomised controlled trials: can scientific experiments be replicated in clinical medicine? What are the philosophical criticisms levelled at RCTs? The concept of evidence in medical research: what do we mean by ‘Evidence-based medicine?’ Should all medicine be based on evidence? Causation in medicine What do advances in neuroscience reveal about the relationship between mind and body? Defining health and disease: are explanations of disease objective or do they depend on values? Evolutionary medicine: what is the role of evolutionary biology in understanding medicine? Is it relevant? Extensive use of empirical examples and case studies is made throughout the book. These include debates about smoking and cancer, the use of placebos in randomised controlled trials and controversies about research into the causes of HIV and autism. This is an indispendable introduction to those teaching philosophy of medicine and philosophy of science. (shrink)

This anthology of essays presents a sample of studies from recent philosophy of medicine addressing issues which attempt to answer very general (interdependent) questions: (a) what is a disease and what is health? (b) How do we (causally) explain diseases? (c) And how do we distinguish diseases, i.e. define classes of diseases and recognize that an instance X of disease belongs to a given class B? (d) How do we assess and choose cure/ therapy?

This volume addresses some of the most prominent questions in contemporary bioethics and philosophy of medicine: ‘liberal’ eugenics, enhancement, the normal and the pathological, the classification of mental illness, the relation between genetics, disease and the political sphere, the experience of illness and disability, and the sense of the subject of bioethical inquiry itself. All of these issues are addressed from a “continental” perspective, drawing on a rich tradition of inquiry into these questions in the fields of phenomenology, philosophical hermeneutics, (...) French epistemology, critical theory and post-structuralism. At the same time, the contributions engage with the Anglo-American debate, resulting in a fruitful and constructive conversation that not only shows the depth and breadth of continental perspectives in bioethics and medicine, but also opens new avenues of discussion and exploration. (shrink)

Current psychiatric classification adopts a disorder-focused diagnostic approach, as exemplified within ICD-11 and DSM-V. Although this approach has improved reliability of categorization, its validity and utility has been questioned. Limitations include high comorbidity between supposedly distinct disorders; heterogeneity within diagnoses; limited treatment efficacy; and similarities across disorders in aetiology, latent symptom structure, and underlying biology. There is also evidence of transdiagnostic cognitive-behavioural processes. An alternative approach is therefore to focus on fundamental underlying mechanisms of psychopathology rather than observed symptom clusters. (...) This article considers the possible benefits, hurdles, and steps towards implementation of this transdiagnostic mechanistic approach, using the example of repetitive negative thought. (shrink)

The introduction of the Diagnostic and Statistical Manual of Mental Disorders in May 2013 is being hailed as the biggest event in psychiatry in the last 10 years. In this paper I examine three important issues that arise from the new manual: Expanding nosology: Psychiatry has again broadened its nosology to include human experiences not previously under its purview. Consequence-based ethical concerns about this expansion are addressed, along with conceptual concerns about a confusion of "construct validity" and "conceptual validity" and (...) a failure to distinguish between "disorder" and "nondisordered conditions for which we help people." The role of claims about societal impact in changes in nosology: Several changes in the DSM-5 involved claims about societal impact in their rationales. This is due in part to a new online open comment period during DSM development. Examples include advancement of science, greater access to treatment, greater public awareness of condition, loss of identify or harm to those with removed disorders, stigmatization, offensiveness, etc. I identify and evaluate four importantly distinct ways in which claims about societal impact might operate in DSM development. Categorisation nosology to spectrum nosology: The move to "degrees of severity" of mental disorders, a major change for DSM-5, raises concerns about conceptual clarity and uniformity concerning what it means to have a severe form of a disorder, and ethical concerns about communication. (shrink)

The introduction of the Diagnostic and statistical manual of mental disorders in May 2013 is being hailed as the biggest event in psychiatry in the last 10 years. In this paper I examine three important issues that arise from the new manual: Expanding nosology: Psychiatry has again broadened its nosology to include human experiences not previously under its purview . Consequence-based ethical concerns about this expansion are addressed, along with conceptual concerns about a confusion of “construct validity” and “conceptual validity” (...) and a failure to distinguish between “disorder” and “non disordered conditions for which we help people.” The role of claims about societal impact in changes in nosology: Several changes in the DSM-5 involved claims about societal impact in their rationales. This is due in part to a new online open comment period during DSM development. Examples include advancement of science, greater access to treatment, greater public awareness of condition, loss of identify or harm to those with removed disorders, stigmatization, offensiveness, etc. I identify and evaluate four importantly distinct ways in which claims about societal impact might operate in DSM development. Categorisation nosology to spectrum nosology: The move to “degrees of severity” of mental disorders, a major change for DSM-5, raises concerns about conceptual clarity and uniformity concerning what it means to have a severe form of a disorder, and ethical concerns about communication. (shrink)

In this volume, leading philosophers of psychiatry examine psychiatric classification systems, including the Diagnostic and Statistical Manual of Mental Disorders, asking whether current systems are sufficient for effective diagnosis, treatment, and research. Doing so, they take up the question of whether mental disorders are natural kinds, grounded in something in the outside world. Psychiatric categories based on natural kinds should group phenomena in such a way that they are subject to the same type of causal explanations and respond similarly to (...) the same type of causal interventions. When these categories do not evince such groupings, there is reason to revise existing classifications. The contributors all question current psychiatric classifications systems and the assumptions on which they are based. They differ, however, as to why and to what extent the categories are inadequate and how to address the problem. Topics discussed include taxometric methods for identifying natural kinds, the error and bias inherent in DSM categories, and the complexities involved in classifying such specific mental disorders as "oppositional defiance disorder" and pathological gambling. -/- Contributors George Graham, Nick Haslam, Allan Horwitz, Harold Kincaid, Dominic Murphy, Jeffrey Poland, Nancy Nyquist Potter, Don Ross, Dan Stein, Jacqueline Sullivan, Serife Tekin, Peter Zachar. (shrink)

The classification of mental disorders based on their phenomenal picture is in crisis and we need a new revolutionary classification primarily based on brain functions: mental disorders shall be derived from dysfunctions of brain circuits performing specific mental functions. This sentence could be taken from a today’s paper discussing the crisis of the DSM-5 and the RDoC Project as a possible revolutionary model based on brain/cognitive dysfunctions. But this same sentence applies very well to the proposal of a new classification (...) and a new statistics written in the 19th century by the South-Italian alienist B.G. Miraglia, entitled “Outlines of a new classification and a new statistics of mental alienations based on phrenological principles considered in their relationship with brain pathology”. In his book Miraglia relies on Gall’s phrenological description of the localization of mental functions in the brain structure. He applies these principles to mental illness, deriving his classification from the primary functions that are supposed to be altered. In this way, the description of the syndrome as it presents itself at the phenomenal level is reconsidered as the output of basic alterations in brain functioning, thus deriving a clear, simple and rigorous classification. The increased activity of all mental functioning produces a general hyperactivity called Mania; the increased activity of only a few brain areas produces a partial hyperactivity, of which several forms may occur depending on the altered brain circuit; the general depression of mental functioning is responsible of a phenomenal picture called Melancholia, while the depressed functioning of only some brain localizations lead to several possible forms of Mono-melancholia; finally, inertia of brain functions may produce Dementia or Partial Dementia, while a deficit of activity due to altered brain conformation is responsible of Idiotism or Partial Idiotism. The reader will probably find odd and funny the names of the functions attributed to discrete brain areas; however, it should be admitted that the procedure is logically cogent and rigorous, and not theoretically so different when compared to contemporary neo-phrenological ideas in 21st century neuroscience. Are we all sure that in the 23rd century our current localizations of brain functions will look very differently? (shrink)

The publication of DSM-5 has been accompanied by a fair amount of controversy. Amongst DSM’s most vocal ‘insider’ critics has been Thomas Insel, Director of the US National Institute of Mental Health. Insel has publicly criticised DSM’s adherence to a symptom-based classification of mental disorder, and used the weight of the NIMH to back a rival research strategy aimed at a more biology-based diagnostic classification. This strategy is part of Insel’s vision of a future, more preventative psychiatry in which mental (...) disorders are not only understood as biological disorders of the brain, but also as neurodevelopmental disorders. This paper examines the interest and merit of Insel’s views of mental and neurodevelopmental disorder for the philosophy of psychopathology, with a special focus of his neurodevelopmental model of schizophrenia. Pitman’s ‘moderate materialism’ will be used both as a philosophical lens through which to examine Insel’s position, as well as an example of a philosophical framework that may require updating and revision in the light of moves towards a neurodevelopmental conception of mental disorder. (shrink)

The question of how psychiatric classifications are made up and to what they refer has attracted the attention of philosophers in recent years. In this paper, I review the claims of authors who discuss psychiatric classification in terms referring both to the philosophical tradition of natural kinds and to the sociological tradition of social constructionism — especially those of Ian Hacking and his critics. I examine both the ontological and the social aspects of what it means for something to be (...) a mental disorder, and how the ontological status of these disorders hinges on social causation. Finally, I conclude by suggesting a way in which the biological and the social may be reconciled in an integrative model of variation in psychiatric disorder. (shrink)

The recent publication of DSM-5 highlighted the two opposing views that exist within psychology and psychiatry as to how we deal with mental disorders. This book provides an introduction to the history of psychiatry and clinical psychology, looking at how people have attempted to classify the various problems and disorders they face.

Identifying the necessary and sufficient conditions for individuating and classifying diseases is a matter of great importance in the fields of law, ethics, epidemiology, and of course, medicine. In this paper, I first propose a means of achieving this goal, ensuring that no two distinct disease-types could correctly be ascribed to the same disease-token. I then posit a metaphysical ontology of diseases—that is, I give an account of what a disease is. This is essential to providing the most effective means (...) of interfering with disease processes. Following existing work in the philosophy of medicine and epidemiology (primarily Christopher Boorse; Caroline Whitbeck; Alexander Broadbent), philosophy of biology (Joseph LaPorte; D.L. Hull), conditional analyses of causation (J.L. Mackie; David Lewis), and recent literature on dispositional essentialism (Stephen Mumford and Rani Anjum; Alexander Bird), I endorse a dispositional conception of disease. Following discussion of various conceptions of disease-identity, their relations to the clinical and pathological effects of the diseases in question, and how diseases are treated, I conclude (i) that diseases should be individuated by their causes, and (ii) that diseases are causal processes best seen as simultaneously acting sequences of mutually manifesting dispositions. (shrink)

The scientific investigation of mental disorders is an invigorating area of inquiry for philosophers of mind and science who are interested in exploring the nature of typical and atypical cognition as well as the overarching scientific project of ‘carving nature at its joints’. It is also important for philosophers of medicine and bioethicists who are concerned with concepts of disease and with the development of effective and ethical treatments of mental disorders and the just distribution of mental health services. Philosophical (...) worries surrounding mental health and its care have recently extended beyond the bounds of academia, becoming a vigorous topic of debate in a variety of public domains in the wake of the publication of the most recent revision of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition , the psychiatric classification system used by mental health professionals in the USA, and increasingly, by those around the world.The DSM-5 lists mental disorders according to the observable symptoms presented by patients. It is designed for pragmatic use across a variety of settings to accomplish several tasks: to facilitate clinical treatment, to provide clear criteria of eligibility for various administrative and policy related purposes ), and primarily, to further scientific research into mental disorder aetiology. Although designed to meet the needs and interests of various stakeholders , the recently revised manual has not fully satisfied any of them. This failure challenges the assumption that a single manual …. (shrink)

Using the conceptual tools of philosopher of science Ludwik Fleck, I argue that the reframing of autism as a neurodevelopmental spectrum disorder is constrained by two governing ‘styles of thought’ of contemporary psychiatry. The first is the historically conditioned ‘readiness for directed perception’ of, and thinking in terms of, ontologically distinct diseases. The clinical gaze of mental health professionals, the bureaucratic needs of health administration, the clinical and scientific utility of disease categories, and the practices of autism-oriented advocacy groups all (...) imply a bias toward thinking about autism and related disorders as ontologically distinct psychiatric and scientific entities. Second, within the ‘neuromolecular style of thought’, mental disorders are more and more located at the neurobiological levels of the brain. In autism research, one of the biggest challenges is the identification of autism's neurobiological singularity. However, at a moment when biological and categorical approaches toward autism face serious empirical difficulties, a balance is established that holds together these two styles of thought. With a need to account for some of the most persistent uncertainties and conflicts in autism research, namely ubiquitous heterogeneity and a failure to identify disease specific biomarkers, the reframing of autism as a neurodevelopmental spectrum disorder satisfies the scientific, institutional and socio-political needs for stability and homogenization. (shrink)

The term, idiopathic, emerged as a key concept in the classification of disease in the 18th century and has become ingrained in our terminology in defining diseases and their aetiologies throughout all fields of medicine. Despite, or perhaps because of this, little has been written about the meaning or meanings of the word itself. Although most medical professionals will be able to offer a definition of idiopathic, different definitions of the word are in use and are often confused or used (...) without an appreciation of the range of meanings. This article aims to clarify these different meanings with reference to historic and current uses. The change from the earlier nosological definition of ‘primary’ to the most widely accepted current definition, ‘of unknown cause’, occurred in the late 19th century, reflecting changing perspectives of disease causation. Far from being an innocent translation of ‘unknown’, idiopathic creates problems for future terminology and adds little to medical understanding. In masking the unknown, the term idiopathic maintains a paternalistic patient–practitioner relationship, and so should be avoided in modern medical terminology. (shrink)

What was classification as it first took modern form in the eighteenth century, how did it work, and how did it relate to earlier describing and ordering? We offer new answers to these questions by considering an example less well known than that of botany or zoology, namely medicine, and by reconstructing practice on paper. The first and best-known disease classification is the “nosology” of the Montpellier physician François Boissier de Sauvages de Lacroix. Its several editions, we show, were less (...) products than process: published tools for building a classification system. The disorder of a hitherto unstudied notebook that Boissier de Sauvages kept throughout this process provided a way of breaking with the topical order of earlier physicians’ humanistic commonplace books of disease observation while sustaining the paper practices those earlier physicians—and Sauvages himself as a student—had used to order disease. This suggests a different picture of historical change than that of a scholarly world of ordered words giving way to a scientific one of ordered things. Classification, in the case of Sauvages’ nosology, arose through an incomplete break with, and intensified practice of, a past way of ordering the described world. The humanist paper practice that had made observationes, differently applied, now made species. Classification into genera and species by similarity and difference, which Sauvages’ nosology shared with botany, was an algorithm of paper and ink practice—in its operation more machine-like than humanist textual practice yet in its effects more creative and re-creative of categories and questions of relationship. Thus a new empiricism of generalizations arose out of the older, Renaissance empiricism of particulars. (shrink)

The Neurological Disease Ontology (ND) is being developed to provide a comprehensive framework for the representation of neurological diseases (Diehl et al., 2013). ND utilizes the model established by the Ontology for General Medical Science (OGMS) for the representation of entities in medicine and disease (Scheuermann et al., 2009). The goal of ND is to include information for each disease concerning its molecular, genetic, and environmental origins, the processes involved in its etiology and realization, as well as its clinical presentation (...) including signs and symptoms. (shrink)

In this paper, I explain why evolutionary psychiatry is not where the next revolution in psychiatry will come from. I will proceed as follows. Firstly, I will review some of the problems commonly attributed to current nosologies, more specifically to the DSM. One of these problems is the lack of a clear and consensual definition of mental disorder; I will then examine specific attempts to spell out such a definition that use the evolutionary framework. One definition that deserves particular attention, (...) is one put forward by Jerome Wakefield. Despite my sympathy for his position, I must indicate a few reasons why I think his attempt might not be able to resolve the problems related to current nosologies. I suggest that it might be wiser for an evolutionary psychiatrist to adopt the more integrative framework of “treatable conditions”. As it is thought that an evolutionary approach can contribute to transforming the way we look at mental disorders, I will provide the reader with a brief sketch of the basic tenets of evolutionary psychology. The picture of the architecture of the human mind that emerges from evolutionary psychology is thought by some to be the crucial backdrop to identifying specific mental disorders and distinguishing them from normal conditions. I will also provide two examples of how evolutionary thinking is supposed to change our thinking about some disorders. Using the case of depression, I will then show what kind of problems evolutionary explanations of particular psychopathologies encounter. In conclusion, I will evaluate where evolutionary thinking leaves us in regard to what I identify as the main problems of our current nosologies. I’ll then argue that the prospects of evolutionary psychiatry are not good. (shrink)

A repository of clinically associated Staphylococcus aureus (Sa) isolates is used to semi‐automatically generate a set of application ontologies for specific subfamilies of Sa‐related disease. Each such application ontology is compatible with the Infectious Disease Ontology (IDO) and uses resources from the Open Biomedical Ontology (OBO) Foundry. The set of application ontologies forms a lattice structure beneath the IDO‐Core and IDO‐extension reference ontologies. We show how this lattice can be used to define a strategy for the construction of a new (...) taxonomy of infectious disease incorporating genetic, molecular, and clinical data. We also outline how faceted browsing and query of annotated data is supported using a lattice application ontology. (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)

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 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)

Classification shapes medicine and guides its practice. As clinicians classify symptoms and illnesses, they trigger a range of actions and consequences. The assignment of particular disease labels is linked to both therapeutic and social responses. However, the classifications of medicine, natural though they may seem, contain significant social content, and are arrived at via a number of cultural framing devices (Aronowitz 2008). This article will explore the social intent and construction of classification and their embodiment in medical diagnosis.Effective classification recognizes (...) difference as well as similarity. By classifying, we are putting items together that have more in common with one another than they .. (shrink)