Nosology

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)

Murphy (2006) criticizes psychiatric nosology 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)

Using methods from anthropology and cognitive psychology, this study investigated the relationship between clinicians’ folk taxonomies of mental disorder and the Diagnostic and Statistical Manual of Mental Disorders (DSM). Expert and novice psychologists were given sixty-seven DSM-IV diagnoses, asked to discard unfamiliar diagnoses, put the remaining diagnoses into groups that had “similar treatments” using hierarchical (making more inclusive and less inclusive groups) and dimensional (placing groups in a two-dimensional space) methodologies, and give names to the groups in their taxonomies. Clinicians (...) were familiar with a substantially smaller number of diagnoses than are in the DSM. Cultural consensus analysis and follow-up residual agreement analysis revealed similarities across clinicians’ folk taxonomies. Correlations between folk taxonomies and the DSM were moderate. Cluster analysis showed that clinicians preserved DSM higher order categories (e.g., mood disorders) but not the Axis I–Axis II distinction. This study suggests important differences between the way clinicians conceptualize mental disorders and the organization of the DSM-IV. (shrink)

Mental health research and care in the twenty first century faces a series of conceptual and ethical challenges arising from unprecedented advances in the neurosciences, combined with radical cultural and organisational change. The Oxford Textbook of Philosophy of Psychiatry is aimed at all those responding to these challenges, from professionals in health and social care, managers, lawyers and policy makers; service users, informal carers and others in the voluntary sector; through to philosophers, neuroscientists and clinical researchers. Organised around a series (...) of case studies in five key topic areas - concepts of disorder, the philosophical history of psychopathology, philosophy of science, ethics and philosophical value theory, and philosophy of mind - the book provides a detailed introduction to the field and a framework for study and skill development. Each case study is supported by selected readings from both philosophy and mental health, thinking skills exercises, self-test questions, key learning points and detailed guides to further reading. There is an introduction for philosophers to classification and descriptive psychopathology, and for practitioners to philosophical methods (including logic). The philosophical topics covered include philosophical methods (analytic and Continental); phenomenology, hermeneutics and existentialism, logical empiricism and its successors; idealism and realism; reasons and causes; and modern theories of mind and brain, free will and personal identity. Topics from mental health include psychiatry and 'anti-psychiatry'; Jaspers' psychopathology and the new neurosciences; the future of psychiatric classifications; strengths-based approaches, recovery practice, social inclusion and diversity; and key topics in psychopathology, such as delusion, autism, disorders of volition, thought insertion and other experiences in schizophrenia. The Oxford Textbook of Philosophy of Psychiatry aims to secure the skills-base of the discipline by bringing philosophers closer to the realities of practice in mental health, and mental health practitioners closer to the resources of philosophy as a partner to the sciences in responding to the challenges of twenty-first century mental health and social care. (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)

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.

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 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)

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)

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)

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

In the target article, Cramer et al. suggest that diagnostic classification is improved by modeling the relationship between manifest variables (i.e., symptoms) rather than modeling unobservable latent variables (i.e., diagnostic categories such as Generalized Anxiety Disorder). This commentary discusses whether symptoms represent manifest or latent variables and the implications of this distinction for diagnosis and treatment.

_The first part called the Preamble tackles: (a) the issues of silence and speech, and life and disease; (b) whether we need to know some or all of the truth, and how are exact science and philosophical reason related; (c) the phenomenon of Why, How, and What; (d) how are mind and brain related; (e) what is robust eclecticism, empirical/scientific enquiry, replicability/refutability, and the role of diagnosis and medical model in psychiatry; (f) bioethics and the four principles of beneficence, non-malfeasance, (...) autonomy, and justice; (g) the four concepts of disease, illness, sickness, and disorder; how confusion is confounded by these concepts but clarity is imperative if we want to make sense out of them; and how psychiatry is an interim medical discipline. The second part called The Issues deals with: (a) the concepts of nature and nurture; the biological and the psychosocial; and psychiatric disease and brain pathophysiology; (b) biology, Freud and the reinvention of psychiatry; (c) critics of psychiatry, mind-body problem and paradigm shifts in psychiatry; (d) the biological, the psychoanalytic, the psychosocial and the cognitive; (e) the issues of clarity, reductionism, and integration; (f) what are the fool-proof criteria, which are false leads, and what is the need for questioning assumptions in psychiatry. The third part is called Psychiatric Disorder, Psychiatric Ethics, and Psychiatry Connected Disciplines. It includes topics like (a) psychiatric disorder, mental health, and mental phenomena; (b) issues in psychiatric ethics; (c) social psychiatry, liaison psychiatry, psychosomatic medicine, forensic psychiatry, and neuropsychiatry. The fourth part is called Antipsychiatry, Blunting Creativity, etc. It includes topics like (a) antipsychiatry revisited; (b) basic arguments of antipsychiatry, Szasz, etc.; (c) psychiatric classification and value judgment; (d) conformity, labeling, and blunting creativity. The fifth part is called The Role of Philosophy, Religion, and Spirituality in Psychiatry. It includes topics like (a) relevance of philosophy to psychiatry; (b) psychiatry, religion, spirituality, and culture; (c) ancient Indian concepts and contemporary psychiatry; (d) Indian holism and Western reductionism; (e) science, humanism, and the nomothetic-idiographic orientation. The last part, called Final Goal, talks of the need for a grand unified theory. The whole discussion is put in the form of refutable points._. (shrink)

Essential Philosophy of Psychiatry is a concise introduction to the growing field of philosophy of psychiatry. Divided into three main aspects of psychiatric clinical judgement, values, meanings and facts, it examines the key debates about mental health care, and the philosophical ideas and tools needed to assess those debates, in six chapters. In addition to outlining the state of play, Essential Philosophy of Psychiatry presents a coherent and unified approach across the different debates, characterized by a rejection of reductionism and (...) an emphasis on the ineliminability of uncodified skilled judgement. The first part, Values, outlines the debate about whether diagnosis of mental illness is essentially value-laden and argues that the prospects for reducing illness or disease to plainly factual matters are poor. It also explains the important role of skilled contextual judgement, rather than a principles-based deduction, in ethical judgement. The second part, Meanings, examines the central role of understanding and a shared first person perspective, both against attempts to reduce meaning to basic information-processing mechanisms and to explain away the difficulties of understanding psychopathology in recent models of delusion. The third part, Facts, shows the importance of uncodified clinical judgements, both in assessing the validity of psychiatric taxonomy and in the application of Evidence Based Medicine. Despite advances in the codifaction of practice and operationalism of diagnosis, an element of judgement remains in the assessment both of what, at one level, is good evidence for diagnosis and treatment and what, at a higher level, is good evidence for the validity of classification overall. (shrink)

The DSM-III, DSM-IV, DSM-IV-TR and ICD-10 have judiciously minimized discussion of etiologies to distance clinical psychiatry from Freudian psychoanalysis. With this goal mostly achieved, discussion of etiological factors should be reintroduced into the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. A research agenda for the DSM-V advocated the "development of a pathophysiologically based classification system". The author critically reviews the neuroevolutionary literature on stress-induced and fear circuitry disorders and related amygdala-driven, species-atypical fear behaviors of clinical severity in adult (...) humans. Over 30 empirically testable/falsifiable predictions are presented. It is noted that in DSM-IV-TR and ICD-10, the classification of stress and fear circuitry disorders is neither mode-of-acquisition-based nor brain-evolution-based. For example, snake phobia and dog phobia are clustered together. Similarly, research on blood-injection-injury-type-specific phobia clusters two fears different in their innateness: 1) an arguably ontogenetic memory-trace-overconsolidation-based fear and 2) a hardwired fear of the sight of one's blood or a sharp object penetrating one's skin. Genetic architecture-charting of fear-circuitry-related traits has been challenging. Various, non-phenotype-based architectures can serve as targets for research. In this article, the author will propose one such alternative genetic architecture. This article was inspired by the following: A) Nesse's "Smoke-Detector Principle", B) the increasing suspicion that the "smooth" rather than "lumpy" distribution of complex psychiatric phenotypes may in some cases be accounted for by oligogenic transmission, and C) insights from the initial sequence of the chimpanzee genome and comparison with the human genome by the Chimpanzee Sequencing and Analysis Consortium published in late 2005. Neuroevolutionary insights relevant to fear circuitry symptoms that primarily emerge overconsolidationally are presented. Also introduced is a human-evolution-based principle for clustering innate fear traits. The "Neuroevolutionary Time-depth Principle" of innate fears proposed in this article may be useful in the development of a neuroevolution-based taxonomic re-clustering of stress-triggered and fear-circuitry disorders in DSM-V. Four broad clusters of evolved fear circuits are proposed based on their time-depths: 1) Mesozoic circuits hardwired by wild-type alleles driven to fixation by Mesozoic selective sweeps; 2) Cenozoic circuits relevant to many specific phobias; 3) mid Paleolithic and upper Paleolithic circuits ; 4) Neolithic circuits. More importantly, the author presents evolutionary perspectives on warzone-related PTSD, Combat-Stress Reaction, Combat-related Stress, Operational-Stress, and other deployment-stress-induced symptoms. The Neuroevolutionary Time-depth Principle presented in this article may help explain the dissimilar stress-resilience levels following different types of acute threat to survival of oneself or one's progency. PTSD rates following exposure to lethal inter-group violence are usually 5-10 times higher than rates following large-scale natural disasters such as forest fires, floods, hurricanes, volcanic eruptions, and earthquakes. The author predicts that both intentionally-caused large-scale bioevent-disasters, as well as natural bioevents such as SARS and avian flu pandemics will be an exception and are likely to be followed by PTSD rates approaching those that follow warzone exposure. During bioevents, Amygdala-driven and locus-coeruleus-driven epidemic pseudosomatic symptoms may be an order of magnitude more common than infection-caused cytokine-driven symptoms. Implications for the red cross and FEMA are discussed. It is also argued that hospital phobia as well as dog phobia, bird phobia and bat phobia require re-taxonomization in DSM-V in a new "overconsolidational disorders" category anchored around PTSD. The overconsolidational spectrum category may be conceptualized as straddling the fear circuitry spectrum disorders and the affective spectrum disorders categories, and may be a category for which Pitman's secondary prevention propranolol regimen may be specifically indicated as a "morning after pill" intervention. Predictions are presented regarding obsessive-compulsive disorder and "culture-bound" acute anxiety symptoms. Also discussed are insights relevant to pseudoneurological symptoms and to the forthcoming Dissociative-Conversive disorders category in DSM-V, including what the author terms fright-triggered acute pseudo-localized symptoms. Speculations based on studies of the human abnormal-spindle-like, microcephaly-associated gene, the microcephaly primary autosomal recessive gene, and the forkhead box p2 gene are made and incorporated into what is termed "The pre-FOXP2 Hypothesis of Blood-Injection-Injury Phobia." Finally, the author argues for a non-reductionistic fusion of "distal neurobiology" with clinical "proximal neurobiology," utilizing neurological heuristics. It is noted that the value of re-clustering fear traits based on behavioral ethology, human-phylogenomics-derived endophenotypes and on ontogenomics can be confirmed or disconfirmed using epidemiological or twin studies and psychiatric genomics. (shrink)

In _ Psychiatry in the Scientific Image, _Dominic Murphy looks at psychiatry from the viewpoint of analytic philosophy of science, considering three issues: how we should conceive of, classify, and explain mental illness. If someone is said to have a mental illness, what about it is mental? What makes it an illness? How might we explain and classify it? A system of psychiatric classification settles these questions by distinguishing the mental illnesses and showing how they stand in relation to one (...) another. This book explores the philosophical issues raised by the project of explaining and classifying mental illness. Murphy argues that the current literature on mental illness -- exemplified by the Diagnostic and Statistical Manual of Mental Disorders -- is an impediment to research; it lacks a coherent concept of the mental and a satisfactory account of disorder, and yields too much authority to commonsense thought about the mind. He argues that the explanation of mental illness should meet the standards of good explanatory practice in the cognitive neurosciences, and that the classification of mental disorders should group symptoms into conditions based on the causal structure of the normal mind. (shrink)

This is a comprehensive resource of original essays by leading thinkers exploring the newly emerging interdisciplinary field of the philosophy of psychiatry. The contributors aim to define this exciting field and to highlight the philosophical assumptions and issues that underlie psychiatric theory and practice, the category of mental disorder, and rationales for its social, clinical, and legal treatment.

This theoretical study highlights the silent yet salient impact of politics, culture, science, and power on the constitution of theories and on the definitions and classifications of psychopathology. The paradoxical notion suggested in this study is that the institution of psychotherapy in particular and the "scientific" field of psychology in general may construct and perpetuate the dysfunction, disease, disorder, and the very psychopathology that they attempt to heal or cure. ;The theoretical approach applied in this study represents an inter-disciplinary review (...) of selected theoretical formulations and clinical observations from clinical and critical psychology, psychoanalysis, family therapy, social psychology, psychiatry, anti-psychiatry, philosophy, linguistics, social constructionism, and interpersonal communication theories. ;It is suggested that taking current psychological concepts, categories, and theories for granted creates and intensifies an "invisible" and under-recognized gap between theory and practice. This study attempts to bring this gap into our professional awareness and to re-investigate notions of psychopathology in this light. (shrink)

In recent years both philosophers and scientists have asked whether or not our current kinds of mental disorder—e.g., schizophrenia, depression, bipolar disorder—are natural kinds; and, moreover, whether or not the search for natural kinds of mental disorder is a realistic desideratum for psychiatry. In this dissertation I clarify the sense in which a kind can be said to be “natural” or “real” and argue that, despite a few notable exceptions, kinds of mental disorder cannot be considered natural kinds. Furthermore, I (...) contend that psychopathological phenomena do not cluster together into kinds in the way that paradigmatic natural kinds do; and, in light of this fact, I conclude that the normative ideal of natural classification—i.e. classifying real or natural kinds—is not appropriate as a general strategy for psychiatry. In the conclusion to this dissertation I propose an alternative way forward. Rather than assuming a priori that psychopathological phenomena cluster together into kinds, a more tractable and theoretically promising approach would be to first explain how particular kinds of experiences and behaviours—e.g, hallucinations, delusions, disorganized thinking, mania, low mood, etc.—are produced. (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)

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)

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)

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)

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)

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 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)

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)

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)

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)

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)

Medical classification systems aim to provide a manageable taxonomy for sorting diagnoses into their proper classes. The question, this paper wants to critically examine, is how to correctly systematise diseases within classification systems that are applied in a variety of different settings. ICD and DSM , the two major classification systems in medicine and psychiatry, will be the main subjects of this paper; however, the arguments are not restricted to these classification systems but point out general methodological and epistemological challenges (...) of classifying diseases for differing purposes. Deciding what qualifies as a disease to be included into a classification system as well as choosing a specific validator for correctly systematising diseases is complicated because the broad applicability of medical classification systems simultaneously appears as aim and challenge. Drawing upon the case study of classifying Alzheimer’s disease, this paper will address three dilemmas in designing ‘good’ medical classification systems. They are due to general epistemological problems of medicine, such as the relationship between individual manifestations of diseases and the necessity of building groups in order to scientifically elucidate causes of diseases. Moreover, they involve pragmatic issues of designing usable classifications that allow for easily discriminating between classes of diseases, restricting, however, the completeness of disease representations. This paper wants to trace how the choice of certain validators is unavoidably value-laden and deeply intertwined with epistemological assumptions of how different uses relate to each other, resulting either in a prioritisation of (constrained) coherence or of (vague) pluralistic connectibility. (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 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 psychiatric nosology 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)

While classifications of mental disorders have existed for over one hundred years, it still remains unspecified what terms such as 'mental disorder', 'disease' and 'illness' might actually denote. While ontologies have been called in aid to address this shortfall since the GALEN project of the early 1990s, most attempts thus far have sought to provide a formal description of the structure of some pre-existing terminology or classification, rather than of the corresponding structures and processes on the side of the patient. (...) We here present a view of mental disease that is based on ontological realism and which follows the principles embodied in Basic Formal Ontology and in the application of BFO in the Ontology of General Medical Science. We analyzed statements about what counts as a mental disease provided in the research agenda for the DSM-V, and in Pies' model. The results were used to assess whether the representational units of BFO and OGMS were adequate as foundations for a formal representation of the entities in reality that these statements attempt to describe. We then analyzed the representational units specific to mental disease and provided corresponding definitions. Our key contributions lie in the identification of confusions and conflations in the existing terminology of mental disease and in providing what we believe is a framework for the sort of clear and unambiguous reference to entities on the side of the patient that is needed in order to avoid these confusions in the future. (shrink)

What is a “mental illness”? What is an “illness”? What does the description and classification of “mental illnesses” actually involve, and is the description of “new” mental illnesses description of actually existing entities, or the creation of them? “Solastalgia” is a neologism, invented by the Australian environmental philosopher Glenn Albrecht, to give greater meaning and clarity to psychological distres s caused by environmental change The concept received some coverage in the international mass media in late 2007 Much of this described (...) solastalgia as “a new concept in mental illness”, a description endorsed by Albrecht himself. The doctor and former British Foreign Secretary, Lord Owen, has coined the phrase “hubris syndrome” to describe the mindset of prime ministers and presidents whose behaviour is characterised by reckless, hubristic belief in their own rightness. This paper uses both the concept of solastalgia and the related concepts Albrecht posited of psychoterratic and somaterratic illnesses and hubris syndrome as a starting point to explore issues around the meaning of mental illness, and what it means to describe and classify mental illness. These issues illustrated tensions between natural and social philosophy, with the nature and status of psychiatry as a scientific, “value-free” enterprise or a humanistic, “value-laden” one discussed. Should “the distress caused by environmental change” be deemed a mental illness? Could it thereby included in catalogues of mental illnesses such as DSM-IV and ICD-10? The process whereby the psychiatric establishment defines and categorises mental illness is described, and as well as examining whether solastalgia and hubris syndrome meets these criteria, those criteria are compare d to more critical views of psychiatry and the nature of mental illness. The approaches of Szasz, Boorse, Fulford, Canguilhem and other thinkers to issues related to mental illness are discussed. Finally it is suggested that the language of mental illness is increasingly used for rhetorical purposes, and that caution should be exercised in extending the label of illness to the phenomena of solastalgia and hubris syndrome. (shrink)

This dissertation examines psychiatry from a philosophy of science perspective, focusing on issues of realism and classification. Questions addressed in the dissertation include: What evidence is there for the reality of mental disorders? Are any mental disorders natural kinds? When are disease explanations of abnormality warranted? How should mental disorders be classified? -/- In addressing issues concerning the reality of mental disorders, I draw on the accounts of realism defended by Ian Hacking and William Wimsatt, arguing that biological research on (...) mental disorders supports the inference that some mental disorders (e.g., schizophrenia, mood disorders, and anxiety disorders) are real theoretical entities, and that the evidence supporting this inference is causal and abductive. In explicating the nature of such entities, I argue that real mental disorders are natural kinds insofar as they are natural classes of abnormal behavior whose members share the same causal structure. I present this position in terms of Richard Boyd’s homeostatic cluster property theory of natural kinds, and argue that this perspective reveals limitations of Hacking’s account on the looping effects of human kinds, which suggests that the objects classified by psychiatrists are unstable entities. I subsequently argue that a subset of mental disorders (e.g., schizophrenia and Down syndrome) are mental illnesses insofar as they are disorders caused by a dysfunctional biological process that leads to harmful consequences for individuals. I present this analysis against Thomas Szasz’s argument that mental illness is a myth. -/- In addressing issues of psychiatric classification, my analysis focuses on the Diagnostic and Statistical Manual of Mental Disorders (DSM), which has been published regularly by the American Psychiatric Association since 1952, and is currently in its fourth edition. After examining the history of DSM in the twentieth century, and in particular, DSM’s shift to an atheoretical and purely descriptive system in the 1980s, I consider the relative merits of descriptive versus causal systems of classification. Drawing on Carl Hempel’s analysis of taxonomic systems in psychiatry, I argue that a causal classification system would provide a superior approach to psychiatric classification than the descriptive system currently favored by DSM. (shrink)

This main article for a Philosophy, Psychiatry, & Psychology philosophical case conference is intended to raise philosophical, psychiatric, and public policy issues concerning the relationship between concepts of criminality, mental disorder, and the classification of mental disorders. After introducing the basic problem of the confounding of “vice” and mental disorder concepts in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition—Text Revision, the author summarizes three different cases from the literature that illustrate the problem of the vice–mental disorder relationship. (...) Four general aspects of the conceptual issues are presented to frame the discussion, and general questions in a range of domains are posed for commentators. (shrink)

This dissertation has three tasks: to analyze the philosophy behind our current psychiatric nosology, to analyze and refute the myriad criticisms of that nosology, and to provide a more sophisticated understanding of what it is to have nosologic validity in general. Whereas most disease classifications do not generate much controversy, the current psychiatric nosology, the Diagnostic and Statistical Manual of Mental Disorders constitutes a nearly universal focus for criticism, usually on philosophical grounds. However, neither critics not proponents of the DSM (...) provide clear and defensible arguments for their positions. In order to remedy this situation, and to clear the way for more productive discussions about the validity of psychiatric nosology, I analyze both the DSM and the criticisms most commonly made of it. I compare psychiatric nosology to other classifications in biology and medicine; and I draw on insights from those sciences to determine which philosophical concerns about the DSM need to be taken seriously. I dispel several sources of misunderstanding about nosologic validity; and I recast questions about the nosologic validity of the DSM in terms of process rather than product. I conclude that in light of the tripartite view of nosologic validity used in psychology, the DSM is valid. However, I challenge the authors of the next edition of the DSM to clarify its methodological and philosophical assumptions so that further confusion about the validity of the DSM might be avoided. (shrink)

What exactly is a genetic disease? For a phrase one hears on a daily basis, there has been surprisingly little analysis of the underlying concept. Medical doctors seem perfectly willing to admit that the etiology of disease is typically complex, with a great many factors interacting to bring about a given condition. On such a view, descriptions of diseases like cancer as geneticseem at best highly simplistic, and at worst philosophically indefensible. On the other hand, there is clearly some practical (...) value to be had by classifying diseases according to theirpredominant cause when this can be accomplished in a theoretically satisfactory manner. The question therefore becomes exactly how one should go about selecting a single causal factor among many to explain the presence of disease. When an attempt to defend such causal selection is made at all, the standard accounts offered (Koch's postulates, Hill's epidemiological criteria, manipulability) are all clearly inadequate. I propose, however, an epidemiological account of disease causation which walks the fine line between practical applicability and theoretical considerations of causal complexity and attempts to compromise between patient-centered and population-centered concepts of disease. The epidemiological account is the most basic framework consistent with our strongly held intuitions about the causal classification of disease, yet it avoids the difficulties encountered by its competitors. (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 study of mental illness by the methods of molecular genetics is still in its infancy, but the use of genetic markers in psychiatry may potentially lead to a Virchowian revolution in the conception of mental illness. Genetic markers may define novel clusters of patients having diverse clinical presentations but sharing a common genetic and mechanistic basis. Such clusters may differ radically from the conventional classification schemes of psychiatric illness. However, the reduction of even relatively simple Mendelian phenomena to molecular (...) genetics has been shown to be a surprisingly complex and problematic enterprise. Mental illnesses exist at many levels of including social, environmental, and developmental interactions. Reductionistic shifts in the classification of such a disease entity will have to address the interlevel dynamics that take place within the structure of theories of mental illness. The question of how molecular analysis of psychiatric disease will impact on the structure of existing theories and classification systems is the central topic of this paper. (shrink)