Philosophy of Psychiatry

This article criticizes the approach to language underlying the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders . Concepts from the philosophy of language illuminate taxonomic problems that vex users of the DSM nosology: lack of coverage, comorbidity, and within-category heterogeneity. Exception is taken to the operationism that results in a highly artificial DSM nomenclature, raising the specter of non-referential criterion sets. A dimensional approach is recommended because it would better correspond to an objectively seamless reality.

The instrumental classification of depression made possible by the Diagnostic and Statistical Manual and the widespread pharmacological approach to treatment in mainstream biopsychiatry has generated a cottage industry of criticism. This paper explores the potential shortcomings of the DSM/bio-psychiatric model and introduces the value of philosophical counseling—specifically by means of integrating the insights of Existentialism and Buddhism—as a way to overcome a number of diagnostic and methodological problems. Philosophical counseling, in this regard, is not overly concerned with the objective question (...) of “What we are?” as biophysical beingswith overt behaviors but with a more fundamental question, namely, “How we are?” that is, how do we experience our existence as finite, impermanent beings, how does this experience shape and determine depressive episodes, and how can we come to accept our own finitude and impermanence? (shrink)

In this commentary, we critique the appropriate behavioural features for evolutionary genetic analysis, the role of the environment, and the viability of a general evolutionary genetic model for all common mental disorders. In light of these issues, we suggest that the authors may have prematurely discounted the role of some of the mechanisms they review, particularly balancing selection. (Published Online November 9 2006).

This paper focuses on one of the original moments of the development of the “phenomenological” current of psychiatry, namely, the psychopathological research of Ludwig Binswanger. By means of the clinical and conceptual problem of schizophrenia as it was conceived and developed at the beginning of the twentieth century, I will try to outline and analyze Binswanger’s perspective from a both historical and epistemological point of view. Binswanger’s own way means of approaching and conceiving schizophrenia within the scientific, medical, and psychiatric (...) context of that time will lead us to grasp the epistemological stakes at the origins of his project of reforming psychiatry by means of phenomenology. I will finally attempt to upgrade and update Binswanger’s project in light of the current reappraisal of phenomenology within the ongoing debate on psychopathology engaged by studies in the field of science and philosophy of mind. (shrink)

This paper aims to show that the classification by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders of a distinct listing of disorders known as Culture-Bound Syndromes is misguided. I argue that the list of CBS comprises either genuine disorders that should be included within the main body of the DSM; or ersatz-disorders that serve a practical role for psychiatrists dealing with patients from certain cultures but will one day be eliminated or assimilated by bona (...) fide DSM classifications. In support of these views I draw on claims from two key themes in the philosophy of science: the claim that all folk explanations for phenomena are thoroughly theoretical and therefore fallible; and the occurrence of theoretical elimination in the history of science. I contend that any ersatz-disorders located in the DSM that are judged to be radically false do not differ in kind from eliminated theories in the history of pre-science. (shrink)

In this study, I seek to provide an accurate account of the subjective experience of the body in anorexia nervosa, and how this differs from nonpathological experiences of the body, while remaining neutral on the disorder’s causes. By applying an understanding of the body as found in the work of Merleau-Ponty and Sartre, I show how the insights provided by these philosophers can help to clarify the subjective experience of the disorder. I build up this account of the experience largely (...) by focusing on first-hand accounts of the disorder, as discussed in memoirs and interviews. In doing this, I intend to show one way in which phenomenological insights can prove to be useful in our understanding of psychiatric .. (shrink)

The Diagnostic and Statistical Manual of Mental Disorders contains the official diagnostic criteria for recognized mental illnesses. Some have asserted that DSM revisions have caused the boundaries of specific disorders to expand to include more behaviors, but no previous research has examined if such expansion is isolated or endemic. The current research consisted of an exploration of revisions to diagnostic criteria for 81 disorders. Each change between editions of the DSM was conceptually analyzed as making the disorder more exclusive or (...) more inclusive in terms of the number of people who could theoretically meet the criteria. Results indicated that 63% of disorders moved toward inclusivity, that each edition of the DSM moved toward inclusivity, and that most types of revisions increase inclusivity. (shrink)

This chapter argues that the modernist agenda, currently dominant in mainstream psychiatry, serves as a disempowering force for service users. By structuring the world of mental health according to a technological logic, this agenda is usually seen as promoting a liberation from "myths" about mental illness that led to stigma and oppression in the past. However, it is argued that this approach systematically separates mental distress from background contextual issues and sidelines non-technological aspects of mental health such as relationships, values, (...) and meanings. This move privileges the gaze of the expert doctor who is trained to understand distress in terms of psychopathology. But, as this move empowers the doctor, it disempowers the service user. In part this is because the priorities of modernist psychiatry are generally at odds with the interests and concerns of services users, particularly those who see themselves as survivors of the mental health system. The chapter examines the implications of this for the psychiatrist's role in working with survivors towards recovery. (shrink)

Introduction : the times they are a changin' -- Doing their best -- Values, evidence, conflict -- What counts as evidence? -- The miracle drug -- The battle for acceptance : defining the relationship between medicine and the world of madness and distress -- The ring -- Foregrounding contexts : what kinds of understanding are appropriate in the world of mental illness? -- Losing Peter -- Mind, language, and meaning -- Beetles -- Ethics before technology : is 'treatment' the best (...) way to think about mental health work? -- Narrative and the ethics of representation -- Meaning and recovery -- Citizenship and the politics of identity -- Are you local? : responding to the challenge of globalization in mental health -- The veil. (shrink)

Patient support tools have drawn on a variety of disciplines, including psychotherapy, social psychology, and social care. One discipline that has not so far been used to support patients is philosophy. This paper proposes that a particular philosophical approach, phenomenology, could prove useful for patients, giving them tools to reflect on and expand their understanding of their illness. I present a framework for a resource that could help patients to philosophically examine their illness, its impact on their life, and its (...) meaning. I explain the need for such a resource, provide philosophical grounding for it, and outline the epistemic and existential gains philosophy offers. Illness often begins as an intrusion on one’s life but with time becomes a way of being. I argue that this transition impacts on core human features such as the experience of space and time, human abilities, and adaptability. It therefore requires philosophical analysis and response. The paper uses ideas from Husserl and Merleau-Ponty to present such a response in the form of a phenomenological toolkit for patients. The toolkit includes viewing illness as a form of phenomenological reduction, thematizing illness, and examining illness as altering the ill person’s being in the world. I suggest that this toolkit could be offered to patients as a workshop, using phenomenological concepts, texts, and film clips to reflect on illness. I conclude by arguing that examining illness as a limit case of embodied existence deepens our understanding of phenomenology. (shrink)

Before broaching our main subject, and exploring why, among all disorders of the mind, obsessive-compulsive disorders have a place apart, I would like to start from a dilemma that is well-known to historians interested in mental disorders. According to one approach, a mental illness X is considered as a bona fide or ‘genuine’ illness if, and only if, it originates from a disturbance of the brain. Its neurobiological form is in this case considered as invariant, whatever cultural veneer might give (...) it a different aspect in accord with historical and local settings. The assumption is that this veneer does not, properly speaking, have any deep grounding in reality... (shrink)

Classifying Madness (Springer, 2005) concerns philosophical problems with the Diagnostic and Statistical Manual of Mental Disorders, more commonly known as the D.S.M. The D.S.M. is published by the American Psychiatric Association and aims to list and describe all mental disorders. The first half of Classifying Madness asks whether the project of constructing a classification of mental disorders that reflects natural distinctions makes sense. Chapters examine the nature of mental illness, and also consider whether mental disorders fall into natural kinds. The (...) second half of the book addresses epistemic worries. Even supposing a natural classification system to be possible in principle, there may be reasons to be suspicious of the categories included in the D.S.M. I examine the extent to which the D.S.M. depends on psychiatric theory, and look at how it has been shaped by social and financial factors. I aim to be critical of the D.S.M. without being antagonistic towards it. Ultimately, however, I am forced to conclude that although the D.S.M. is of immense practical importance, it is unlikely to come to reflect the natural structure of mental disorders. (shrink)

Using the British mental health services as a case study, this book critically reviews the various social, political and intellectual developments which have shaped psychiatric practice and the delivery of mental health services.

The pivotal problem of comorbidity research lies in the psychometric foundation it rests on, that is, latent variable theory, in which a mental disorder is viewed as a latent variable that causes a constellation of symptoms. From this perspective, comorbidity is a (bi)directional relationship between multiple latent variables. We argue that such a latent variable perspective encounters serious problems in the study of comorbidity, and offer a radically different conceptualization in terms of a network approach, where comorbidity is hypothesized to (...) arise from direct relations between symptoms of multiple disorders. We propose a method to visualize comorbidity networks and, based on an empirical network for major depression and generalized anxiety, we argue that this approach generates realistic hypotheses about pathways to comorbidity, overlapping symptoms, and diagnostic boundaries, that are not naturally accommodated by latent variable models: Some pathways to comorbidity through the symptom space are more likely than others; those pathways generally have the same direction (i.e., from symptoms of one disorder to symptoms of the other); overlapping symptoms play an important role in comorbidity; and boundaries between diagnostic categories are necessarily fuzzy. (shrink)

The majority of commentators agree on one thing: Our network approach might be the prime candidate for offering a new perspective on the origins of mental disorders. In our response, we elaborate on refinements (e.g., cognitive and genetic levels) and extensions (e.g., to Axis II disorders) of the network model, as well as discuss ways to test its validity.

The "conservative" holds that mental disorder exculpates only if it is evidence of a standard excuse or justification, i.e., one that a mentally "normal" person could have. The Liberal holds that mental disorder sometimes exculpates in itself. I argue that moral culpability in the case of mental disorder is often moot, and that the real issue is what a court should be allowed to do with such individuals. This undermines the idea that culpability is a necessary condition for sentencing, but (...) we already have that in cases of strict liability, and there seems to be no viable alternative in any case. (shrink)