This chapter examines philosophical issues surrounding the classification of mental disorders by the Diagnostic and Statistical Manual of Mental Disorders (DSM). In particular, the chapter focuses on issues concerning the relative merits of descriptive versus theoretical approaches to psychiatric classification and whether the DSM should classify natural kinds. These issues are presented with reference to the history of the DSM, which has been published regularly by the American Psychiatric Association since 1952 and is currently in its fifth edition. While the (...) first two editions of the DSM adopted a theoretical (psychoanalytic) and etiological approach to classification, subsequent editions of the DSM have adopted an atheoretical and purely descriptive (“neo-Kraepelinian”) approach. It is argued that largest problem with the DSM at present—viz., its failure to provide valid diagnostic categories—is directly related to the purely descriptive methodology championed by the DSM since the third edition of the DSM. In light of this problem, the chapter discusses the prospects of a theoretical and causal approach to psychiatric classification and critically examines the assumption that the DSM should classify natural kinds. (shrink)

Diagnoses are central to the practice of medicine, where they serve a variety of functions for clinicians, patients, and society. They aid communication, explain symptoms, inform predictions, guide therapeutic interventions, legitimize sickness, and authorize access to resources. Insofar as psychiatry is a discipline whose practice is shaped by medical conventions, its diagnoses are sometimes presented as if they serve the same sorts of function as diagnoses in bodily medicine. However, there are philosophical problems that cast doubt on whether the functions (...) of psychiatric diagnoses can legitimately be considered to be equivalent to those of medical diagnoses. The aim of this chapter is to explicate some of these problems, particularly conceptual and epistemological problems pertaining to the roles of diagnoses as explanations. I begin with an overview of the various functions that medical diagnoses normally serve and suggest that many of these functions receive justificatory support from the explanatory roles of the diagnoses. I then present issues regarding the epistemic functions of psychiatric diagnoses and how these issues have featured in the arguments of prominent critics of psychiatry. (shrink)

Jonathan Y. Tsou examines and defends positions on central issues in philosophy of psychiatry. The positions defended assume a naturalistic and realist perspective and are framed against skeptical perspectives on biological psychiatry. Issues addressed include the reality of mental disorders; mechanistic and disease explanations of abnormal behavior; definitions of mental disorder; natural and artificial kinds in psychiatry; biological essentialism and the projectability of psychiatric categories; looping effects and the stability of mental disorders; psychiatric classification; and the validity of the DSM's (...) diagnostic categories. The main argument defended by Tsou is that genuine mental disorders are biological kinds with harmful effects. This argument opposes the dogma that mental disorders are necessarily diseases that result from biological dysfunction. Tsou contends that the broader ideal of biological kinds offers a more promising and empirically ascertainable naturalistic standard for assessing the reality of mental disorders and the validity of psychiatric categories. (shrink)

Are mental disorders natural kinds or socially constructed categories? What is at stake if either of these views prove to be true? This paper offers a qualified defence for the view that there may be natural kinds of mental disorder, but also that the implications of this claim are generally overestimated. Especially concerns about over-inclusiveness of diagnostic categories and medicalisation of abnormal behaviour are not addressed by the debate. To arrive at these conclusions the paper opens with a discussion of (...) kind formation in science, followed by an analysis of natural kinds. Seven principled and empirically informed objections to the possibility of natural kinds of mental disorder are considered and rejected. The paper ends with a reflection on diagnostics of mental health problems that don’t fall into natural kinds. Despite the defence of the possibility of natural kinds of mental disorder, this is likely to be the majority of cases. (shrink)

The paper engages Christopher Boorse’s Bio-Statistical Theory. In its current form, BST runs into a significant challenge. For BST to account for its central tenet—that lower-level part-dysfunction is sufficient for higher-level pathology—it must provide criteria for how to decide which lower-level parts are the ones to be analyzed for health or pathology. As BST is a naturalistic theory, such choices must be based solely on naturalistic considerations. An argument is provided to show that, if BST is to be preserved, such (...) parthood choices are based on non-naturalistic considerations. We demonstrate that even when parthood choices are based on the best way to preserve BST, there are counterintuitive results which bring the central tenet of BST into question. (shrink)

Christopher Boorse’s Health care ethics: an introduction, Temple University Press, Philadelphia, pp 359–393, 1987; in Humber, Almeder, Totowa What is disease?, Humana Press, New York City, pp 1–134, 1997; J Med Philos, 39:683–724, 2014) Bio-Statistical Theory comprehends diseases in terms of departures from natural norms, which involve an objectively describable deviation from the proper physiological or psychological functioning of parts of the human organism. I argue that while recent revisions and additional considerations shield the BST from a number of issues (...) raised by critics, they give rise to significant new challenges. These are related to the attribution of epistemic authority, the possibility of multiple concepts in the authoritative literature, and the framing of BST as “philosophical explication.” The conclusion is that, in its current form, the BST is unable to provide a robust framework for a naturalist classification. (shrink)

Commentary of Justin Garson, "Madness and idiocy: Reframing a basic problem of philosophy of psychiatry." Philosophy, Psychiatry, & Psychology.

This paper examines Ian Hacking's analysis of the looping effects of psychiatric classifications, focusing on his recent account of interactive and indifferent kinds. After explicating Hacking's distinction between 'interactive kinds' (human kinds) and 'indifferent kinds' (natural kinds), I argue that Hacking cannot claim that there are 'interactive and indifferent kinds,' given the way that he introduces the interactive-indifferent distinction. Hacking is also ambiguous on whether his notion of interactive and indifferent kinds is supposed to offer an account of classifications or (...) objects of classification. I argue that these conceptual difficulties show that Hacking's account of interactive and indifferent kinds cannot be based on - and should be clearly separated from - his distinction between interactive kinds and indifferent kinds. In clarifying Hacking's account, I argue that interactive and indifferent kinds should be regarded as objects of classification (i.e., kinds of people) that can be identified with reference to a law-like biological regularity and are aware of how they are classified. Schizophrenia and depression are discussed as examples. I subsequently offer reasons for resisting Hacking's claim that the objects of classification in the human sciences - as a result of looping effects - are 'moving targets'. (shrink)

A significant portion of the scholarship in analytic philosophy of psychiatry has been devoted to the problem of what kind of kind psychiatric disorders are. Efforts have included descriptive projects, which aim to identify what psychiatrists in fact refer to when they diagnose, and prescriptive ones, which argue over that to which diagnostic categories should refer. In other words, philosophers have occupied themselves with what I call “diagnostic kinds”. However, the pride of place traditionally given to diagnostic kinds in psychiatric (...) research has recently come under attack, most notably by a recent initiative of the National Institute of Mental Health, the Research Domain Criteria Project, that seeks to exclude diagnostic categories from experimental designs and focus on other sorts of psychiatric kinds. I argue that philosophical accounts privileging diagnostic kinds must respond to this new line of criticism, and conclude that philosophers need to either counter psychiatrists’ growing suspicion about the hegemony of diagnostic categories in the clinic and the laboratory, or join in redirecting their efforts toward the development of robust accounts of other sorts of psychiatric objects and processes. (shrink)

If a human subject knows they are being measured, this knowledge may affect their attitudes and behaviour to such an extent that it affects the measurement results as well. This broad range of effects is shared under the term ‘reactivity’. Although reactivity is often seen by methodologists as a problem to overcome, in this paper I argue that some quite extreme reactive changes may be legitimate, as long as we are measuring phenomena that are not simple biological regularities. Legitimate reactivity (...) is reactivity which does not undermine the accuracy of a measure; I show that if such reactivity were corrected for, this would unjustifiably ignore the authority of the research subject. Applying this argument to the measurement of depression, I show that under the most commonly accepted models of depression there is room for legitimate reactivity. In the first part of the paper, I provide an inventory of the different types of reactivity that exist in the literature, as well as the different types of phenomena that one could measure. In the second part, I apply my argument to the measurement of depression with the PHQ-9 survey. I argue that depending on what kind of phenomenon we consider depression to be, we will accept different kinds of reactivity. I show that both under the harmful dysfunction model and the practical kinds model, certain reactive changes in measuring depression are best seen as legitimate recharacterizations of the underlying phenomenon, and define what legitimate means in this context. I conclude that in both models, biological aspects constrain characterization, but the models are not so strict that only one concept is acceptable, leaving room for reactivity. (shrink)

The causes and underlying natures of common mental disorders are, for the most part, quite mysterious. Our best taxonomies acknowledge this poverty of causal knowledge about minds, brains, society, and whatever else, to instead classify psychopathology based on clusters of detectable signs and symptoms: what it is to be, say, depressed, is simply to exhibit the minimum number of typical features for the right amount of time. Nothing in this approach references what causes and maintains a characteristic set of symptoms, (...) and so by conceptualizing disorders as syndromes psychiatry stands in stark contrast to somatic medicine, its close cousin, and other successful sciences that classify... (shrink)

The themes of this issue—which include the meaning of our health and disease concepts, the so-called “medical gaze” and its embedded power relations, and the epistemic value of mixing therapy with research—are introduced by reflecting on a case about an infant girl whose head is observed to be somewhat flat.

The key objectives of this book are to demonstrate the applicability of issues in the philosophy of science to problems in psychiatry and to show how the conceptual issues raised by psychiatry should be considered more closely by philosophers of science. These are worthy aims: the philosophy of psychiatry needs to draw more thoughtfully upon contemporary philosophical debates and stimulating interest within the philosophy of science is a good way to do this.Cooper's book succeeds for both of these desiderata. The (...) first five chapters discuss the central issues in the philosophy of psychiatry: whether mental illness is a disease/natural kind and what follows from this. There is a large literature on these questions, some of which …. (shrink)

This paper offers a philosophical analysis of the connection between mental disorder and suicide risk. In contemporary psychiatry, it is commonly suggested that this connection is a causal connection that has been established through empirical discovery. Herein, I examine the extent to which this claim can be sustained. I argue that the connection between mental disorder and increased suicide risk is not wholly causal but is partly conceptual. This in part relates to the way suicidality is built into the definitions (...) of some psychiatric diagnoses. It also relates to the broader normative assumption that suicidal behavior is by definition mentally disordered behavior. The above has significant epistemological implications, which I explore. I propose that the claim that suicide is connected with mental disorder cannot be justified solely by appealing to empirical evidence but also warrants a justification on conceptual and normative grounds. (shrink)

In clinical medicine, a diagnosis can offer an explanation of a patient's symptoms by specifying the pathology that is causing them. Diagnoses in psychiatry are also sometimes presented in clinical texts as if they pick out pathological processes that cause sets of symptoms. However, current evidence suggests the possibility that many diagnostic categories in psychiatry are highly causally heterogeneous. For example, major depressive disorder may not be associated with a single type of underlying pathological process, but with a range of (...) different causal pathways, each involving complex interactions of various biological, psychological, and social factors. This paper explores the implications of causal heterogeneity for whether psychiatric diagnoses can be said to serve causal explanatory roles in clinical practice. I argue that while they may fall short of picking out a specific cause of the patient's symptoms, they can nonetheless supply different sorts of clinically relevant causal information. In particular, I suggest that some psychiatric diagnoses provide negative information that rules out certain causes, some provide approximate or disjunctive information about the range of possible causal processes, and some provide causal information about the relations between the symptoms themselves. (shrink)

According to Ian Hacking, some human kinds are subject to a peculiar type of classificatory instability: individuals change in reaction to being classified, which in turn leads to a revision of our understanding of the kind. Hacking’s claim that these ‘human interactive kinds’ cannot be natural kinds has been vehemently criticized on the grounds that similar patterns of instability occur in paradigmatic examples of natural kinds. I argue that the dialectic of the extant debate misses the core conceptual problem of (...) human interactive kinds. The problem is not that these kinds are particularly unstable but ‘capricious’—their members behave in wayward, unexpected manners that defeats existing theoretical understanding. The reason for that, I argue, is that human interactive kinds are often ‘hybrid kinds’ consisting of a base kind and an associated status, which makes mechanisms that support patterns of change and stability systematically difficult to understand and predict. 1Introduction2The Extant Discussion 2.1Hacking’s account of interactive kinds2.2Classificatory feedback in non-human kinds3Natural kinds and Ontological Instability 3.1Understanding instability3.2The problem of stabilizing feedback3.3Summary4Capricious Kinds 4.1Biased conceptualization4.2Studying social status5Conclusion. (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)

This paper offers an overview of the philosophical work on epistemic injustices as it relates to psychiatry. After describing the development of epistemic injustice studies, we survey the existing literature on its application to psychiatry. We describe how the concept of epistemic injustice has been taken up into a range of debates in philosophy of psychiatry, including the nature of psychiatric conditions, psychiatric practices and research, and ameliorative projects. The final section of the paper indicates future directions for philosophical research (...) of epistemic injustices and psychiatry, concerning neurocognitive disorders, identity prejudices in psychiatric illness, concepts of epistemic privilege in psychiatry, and the prospects for combining phenomenological psychopathology and epistemic justice. We argue that much remains to be done in the conceptualization of these epistemic injustices and suggest that this future work should be multidisciplinary in character and sensitive to the phenomenology of psychiatric conditions. (shrink)

Recently there has been a trend of moving towards biological and neurocognitive based classifications of mental disorders that is motivated by a dissatisfaction with the syndrome-based classifications of mental disorders. The Research Domain Criteria (indicated with the acronym RDoC) represents a bold and systematic attempt to foster this advancement. However, RDoC faces theoretical and conceptual issues that need to be addressed. Some of these difficulties emerge when we reflect on the plausible reading of the slogan “mental disorders are brain disorders”, (...) that according to proponents of RDoC constitutes one of its main presuppositions. Some authors think that endorsing this idea commits RDoC to a form of biological reductionism. We offer empirical and theoretical considerations for concluding that the slogan above should not be read as a reductionist thesis. We argue, instead, that the slogan has a pragmatic function whose aim is to direct research in psychopathology. We show how this function might be captured in the framework of a Carnapian explication as a methodological tool for conceptual engineering. Thus, we argue that a charitable interpretation of the aims of the proponents of RDoC should be understood as an attempt at providing an explication of the concept of mental disorder in terms of brain disorder whose main goal is to provide a more precise and fruitful notion that is expected to have a beneficial impact on classification, research, and treatment of psychiatric conditions. (shrink)

In the 20th century, the boundaries of psychosis emerged as an area in which psychiatric judgement faced numerous and profound uncertainties. Between obvious neuroses and personality and reactive disorders on the one hand, and unquestionable psychoses on the other, psychiatrists faced a world of suspected cases of schizophrenia, doubtful personality disorder diagnoses or probable cases of psychosis constituting a garden of equivocal clinical presentations in which both individual psychiatrists and the discipline as a whole were confronted with the limits of (...) their knowledge. This article examines how psychiatrists from two German university clinics managed the multiple uncertainties involved in diagnosing cases of early psychosis between 1950 and 1980. Based on the analysis of a sample of records, we propose a pragmatic interpretation of the ways in which these uncertainties were recorded by psychiatrists. How were uncertainties and doubts expressed in the records and managed by clinicians? What means were used to dispel doubt? What were the consequences for patients of these diagnostic uncertainties? The article defines an uncertainty diagnosis as a diagnosis expressed with reservations by its author and recorded as such in a medical file. Depending on the nature of the uncertainty, the types of evidence used by the professionals and how this evidence was dealt with, we have identified three types of uncertainty diagnoses: suspicion, plausibility and probability diagnoses. The article then reflects on the role of the patients themselves in shaping these uncertain situations. (shrink)

The distinction between explanation and understanding was foundational to Jaspers’ ‘phenomenological’ approach to psychiatry. It makes sense that those now calling for a phenomenological approach to psychiatry would look to Jaspers for inspiration, and that in doing so, they would take up this distinction. However, I argue that it is and was a mistake to use the distinction in work on psychiatry: adhering to the distinction now would undermine, rather than support, the goals of those advocating a phenomenological approach to (...) psychiatry; furthermore, if the distinction had been adhered to, then contemporary psychiatry and its patients would be worse off. (shrink)

In this article I examine some of the issues involved in taking psychiatric disorders as natural kinds. I begin by introducing a permissive model of natural kind-hood that at least prima facie seems to allow psychiatric disorders to be natural kinds. The model, however, hinges on there in principle being some grounding that is shared by all members of a kind, which explain all or most of the additional shared projectible properties. This leads us to the following question: what grounding (...) do psychiatric disorders qua natural kinds have? My principal method for examining the issue is a case study of a particular psychiatric disorder: the so-called “apathetic children.” I argue that there appear to be at least two competing models that both appeal to non-organic a grounding of the disorder. However, for other psychiatric disorders, such as Alzheimer’s disease, the evidence points toward an organic explanation of the disorder. I contend that what unites psychiatric disorders is not a distinctive type of grounding that all psychiatric disorders share, but the distinctive set of determinable properties that is shared by all psychiatric disorders. (shrink)

Much research in the philosophy of psychiatry has been devoted to the characterization of the normal and the pathological. In this article, we identify and deconstruct two postulates that have held sway in the philosophy of psychiatry. The first postulate concerns the belief that clinicians would benefit from conceiving of psychiatric disorders as stable entities with clear boundaries. By relying on a symptom-based approach, we support a conception of psychiatric disorders whose symptoms are the products of many activated mechanisms in (...) mutual interactions. The second postulate concerns the way in which the philosophy of psychiatry has approached the question of harm. We posit that clinicians perceive harms primarily through networks of clinical manifestations. The identification and deconstruction of these two postulates leads us to propose a practical definition of a psychiatric disorder that is useful for the clinician, while adopting a principle of prudential conservatism that does not exclude other theoretical definitions of psychiatric disorder that are useful as an epistemic hub. Thus, we propose the following definition of a psychiatric disorder that is relevant to clinical practice: “a set of clinical manifestations belonging to the prototypical central core of psychiatry, organized in a causal network, involving at least one harm, and whose set of harms exceeds the traditional threshold of significance for a given psychiatric disorder, directly related to an activated mechanism. Such a network composed of clinical manifestations is frozen in a state that is unable to allow the deactivation of these manifestations spontaneously without a therapeutic intervention”. (shrink)

In this paper, I argue for a new way to understand the integration of facts and values in the concept of mental disorder that has the potential to avoid the flaws of previous hybrid approaches. I import conceptual tools from the account of procedural objectivity defended by Helen Longino to resolve the controversy over the definition of mental disorder. My argument is threefold: I first sketch the history of the debate opposing objectivists and constructivists and focus on the criticisms that (...) led to the emergence of the debate. Second, I offer a reconstruction of the “Natural Function Approach” argument to make explicit an unsound assumption underlying this approach. The reconstruction will allow me to show that the NFO’s argument depends on the ideal of value-free science that I will criticize. Then I propose an alternative ideal for psychiatry: social objectivity. I argue that the concept of mental health should be seen as “socially objective” rather than value-free, moving the debate towards the social procedures by which the definition is produced rather than the normative and factual content of its definition. (shrink)

In the debate over the definition of ‘mental health,’ three different approaches are generally distinguished: the normativist approach, the hybrid approach and the naturalistic approach. This paper qualifies this classification by clarifying the sense in which Christopher Boorse defends a naturalistic approachvis-à-visthe central concepts of psychiatry. This paper also clarifies in what way Boorse is opposed to the normativist approach advocated by some authors of the anti-psychiatric movement, such as Szasz.

Historians and sociologists of psychiatry often claim that psychiatric diagnoses are discontinuous. That is, a particular diagnoses will be described in one way in one era and described quite differently in a different era. Historians and sociologists often draw epistemic consequences from such discontinuities, claiming that truth is pluralistic, provisional and historicised. These arguments do not readily fit in with how analytical philosophers of science approach scientific realism. I show how the pessimistic meta induction does not capture the point which (...) historians and sociologists are making but scientific perspectivism seems to capture their point much better. I then highlight conceptual innovations which scientific perspectivists add. They demarcate between truth and objective reality, they specify which type of truth they endorse and they put down constraints on possible truths. This blocks an anything goes relativism which historians and sociologists can be in danger of falling into. I highlight my argument by discussing a discontinuous episode in the history of autism. I discuss three aspects of this discontinuity and show how scientific perspectivism can portray each aspect as non-trivially true. My argument shows that we can be scientific realists about autism even if we can formulate notions of autism in quite different ways. (shrink)

Critics who are concerned over the epistemological status of psychiatric diagnoses often describe them as being constructed. In contrast, those critics usually see symptoms as relatively epistemologically unproblematic. In this paper I show that symptoms are also constructed. To do this I draw upon the demarcation between data and phenomena. I relate this distinction to psychiatry by portraying behaviour of individuals as data and symptoms as phenomena. I then draw upon philosophers who consider phenomena to be constructed to argue that (...) symptoms are also constructed. Rather than being ready made in the world I show how symptoms are constructs we apply to the world. I highlight this with a historical example and describe methodological constraints on symptom construction. I show the epistemic problems with psychiatric diagnoses are also applicable to symptoms. Following this, I suggest that critics of psychiatric diagnoses should extend their criticism to symptoms or, if they still believe symptoms are relatively epistemologically unproblematic, should rethink their concerns over psychiatric diagnoses. (shrink)

I raise a puzzle case for “cluster” accounts of natural kinds—the homeostatic property cluster and stable property cluster accounts, especially—on the basis of their expected treatment of the metaphysics of certain disease kinds. Some kinds, I argue, fail to exhibit the co-instantiated property clusters these cluster views take to be constitutive of natural kinds. Some genetic diseases, for example, have archetypical instances with few or none of the pathological processes or symptoms associated with the kind: their instances are typified by (...) a single dispositional property. I dub such kinds ‘amorphic’, owing to their limited morphology, and try out a number of ways in which these kinds might be treated in terms of property clusters, adapting responses cluster theorists have offered to the problem of polymorphic species. Finding these responses wanting, I conclude that cluster accounts are unlikely to be the best account of the metaphysics of amorphic kinds. (shrink)

In this paper I discuss a central objection against diseases being natural kinds—namely, that diseases are processes or transitions and hence they should not be conceptualized in the ‘substantish’ framework of natural kinds. I indicate that the objection hinges on conceiving disease kinds as phase kinds, in contrast to the non-phase, natural kinds of the exact sciences. I focus on somatic diseases and argue, via a representative comparison, that if disease kinds are phase kinds, then exact science kinds are phase (...) kinds as well. On the other hand, if exact science kinds are non-phase kinds, then disease kinds are non-phase kinds as well. This objection should thus be rejected, under a certain caveat, though. If natural kind membership has an influence over the diachronic identity of kind members, then it is possible, in principle, to draw the phase/non-phase distinction such that an ‘ontological gap’ lies between medical kinds and exact science kinds. I show further that this caveat is unavoidable even in relation to substantive universals and ‘essential’ properties—two controversial, strong features that were traditionally associated to natural kinds. (shrink)

In this paper, I focus on life-threatening medical conditions and argue that from the point of view of natural properties, induction(s), and participation in laws, at least some of the ill organisms dealt with in somatic medicine form natural kinds in the same sense in which the kinds in the exact sciences are thought of as natural. By way of comparing two ‘divisions of nature’, viz., a ‘classical’ exact science kind (gold) and a kind of disease (Graves disease), I show (...) that there is no justifiable ‘ontological gap’ between disease kinds and exact sciences kinds. We have instead a difference of degree. (shrink)

Boorse’s biostatistical theory states that diseases should be defined in ways that reflect disturbances of biological function and that are objective and value free. We use three examples from contemporary medicine that demonstrate the complex issues that arise when defining the boundaries of disease: polycystic ovary syndrome, chronic kidney disease, and myocardial infarction. We argue that the biostatistical theory fails to provide sufficient guidance on where the boundaries of disease should be drawn, contains ambiguities relating to choice of reference class, (...) and is out of step with medical processes for identifying disease boundaries. Although proponents of the biostatistical theory might regard these practical issues as irrelevant to the aim of providing a theoretical account of disease, we take them to indicate the need for a theoretical account that is adequate for current needs—including limiting new forms of medicalization that are driven by the identification of disease based on dysfunction. Our processes for determining the boundaries for disease need to recognize that there is no value-free method for making these decisions. (shrink)

The DSM is the main classification of mental disorders used by psychiatrists in the United States and, increasingly, around the world. Although widely used, the DSM has come in for fierce criticism, with many commentators believing it to be conceptually flawed in a variety of ways. This paper assesses some of these philosophical worries. The first half of the paper asks whether the project of constructing a classification of mental disorders that ‘cuts nature at the joints’ makes sense. What is (...) mental disorder? Are types of mental disorder natural kinds (that is, are the distinctions between them objective and of fundamental theoretical importance, as are, say, the distinctions between the chemical elements)? The second half of the paper addresses epistemic worries. Even if types of mental disorder are natural kinds there may be reason to doubt that the DSM will come to reflect their natural structure. In particular, I examine the extent to which the DSM is theory-laden, and look at how it has been shaped by social and financial factors. Ultimately, I conclude that although the DSM is of immense practical importance it is not likely to become the best possible classification of mental disorders. (shrink)

This article does not directly consider the feelings and emotions that occur in mental illness. Rather, it concerns a higher level methodological question: To what extent is an analysis of feelings and felt emotions of importance for psychiatric classification? Some claim that producing a phenomenologically informed descriptive psychopathology is a prerequisite for serious taxonomic endeavor. Others think that classifications of mental disorders may ignore subjective experience. A middle view holds that classification should at least map the contours of the phenomenology (...) of mental illness. This article examines these options. I conclude that it is not true that phenomenology is a logical prerequisite for classification, nor even that classification should necessarily respect phenomenological boundaries, but that detailed phenomenological examination can sometimes inform classification. (shrink)

"Psychiatry and Philosophy of Science" explores conceptual issues in psychiatry from the perspective of analytic philosophy of science. Through an examination of those features of psychiatry that distinguish it from other sciences - for example, its contested subject matter, its particular modes of explanation, its multiple different theoretical frameworks, and its research links with big business - Rachel Cooper explores some of the many conceptual, metaphysical and epistemological issues that arise in psychiatry. She shows how these pose interesting challenges for (...) the philosopher of science while also showing how ideas from the philosophy of science can help to solve conceptual problems within psychiatry. Cooper's discussion ranges over such topics as the nature of mental illnesses, the treatment decisions and diagnostic categories of psychiatry, the case-history as a form of explanation, how psychiatry might be value-laden, the claim that psychiatry is a multi-paradigm science, the distortion of psychiatric research by pharmaceutical industries, as well as engaging with the fundamental question whether the mind is reducible to something at the physical level. "Psychiatry and Philosophy of Science" demonstrates that cross-disciplinary contact between philosophy of science and psychiatry can be immensely productive for both subjects and it will be required reading for mental health professionals and philosophers alike. (shrink)

It has recently been suggested that delusions be conceived of as symptoms on the harmful dysfunction account of disorder: delusions sometimes arise from dysfunction, but can also arise through normal cognition. Much attention has thus been payed to the question of how we can determine whether a delusion arises from dysfunction as opposed to normal cognition. In this paper, we consider another question, one that remains under-explored: which delusions warrant treatment? On the harmful dysfunction account, this question dissociates from the (...) question about dysfunction—there are a broad range of “treatable conditions” beyond mere harmful dysfunctions. As such, many conditions that arise from normal cognition are also eligible for medical intervention. We argue that some delusions that arise from normal cognition may well fall under the banner of treatable conditions. We examine the practical and ethical questions surrounding such treatment, including the issue of coercive and deceptive treatment options. (shrink)

Typically, although it’s notoriously hard to define, autism has been represented as a biologically-based mental disorder that can be usefully investigated by biomedical science. In recent years, ho...

The Diagnostic and Statistical Manual of Mental Disorders has elicited numerous criticisms throughout its history. Its particularly controversial status has not been resolved by the recent release of the DSM-5 ; rather, the new edition has amplified debates in psychiatry as well as philosophy and the wider public. To a certain extent, such controversies are to be expected because of the influential role the DSM plays in science and health care. Researchers have often been required to use the DSM classification (...) to get funded and published, clinicians need to use it for diagnosis, and patients need a DSM code to get reimbursed for treatment.1 Classification in psychiatry shapes the course of research... (shrink)

This essay replies to critics since 1995 of my “biostatistical theory” of health. According to the BST, a pathological condition is a state of statistically species-subnormal biological part-functional ability, relative to sex and age. Theoretical health, the total absence of pathological conditions, is then a value-free scientific notion. Recent critics offer a mixture of old and new objections to this analysis. Some new ones relate to choice of reference class, situation-specificity of function, common diseases and healthy populations, improvements in population (...) health, the practice of pathologists, “Cambridge changes” in health status, and comparative vs. absolute health concepts. I make no changes in doctrine, except to consider treating “normal aging” as pathological by taking young adults as the standard for all adults. (shrink)

The notion of harm has been a recurring and a significant notion in the characterization of mental disorder. It is present in eminent diagnostic manuals such as DSM and ICD, as well as in the discussion on mental disorders in philosophy of psychiatry. Recent demotion of harm in the definition of mental disorders in DSM-5 shows a general trend towards reducing the significance of harm when thinking about the nature of mental disorders. In this paper, we defend the relevance of (...) the notion of harm in the characterization of mental disorder against some of these attacks. We approach this issue by using the method of conceptual explication pioneered by Rudolf Carnap. Within this framework, we argue that keeping the notion of harm not only helps to discriminate what is pathological from the nonpathological but also prevents potential misuses of psychiatric authority. (shrink)

Philosophers of medicine have formulated different accounts of the concept of disease. Which concept of disease one assumes has implications for what conditions count as diseases and, by extension, who may be regarded as having a disease and for who may be accorded the social privileges and personal responsibilities associated with being sick. In this article, we consider an ideal diagnostic test for coronavirus disease 2019 infection with respect to four groups of people—positive and asymptomatic; positive and symptomatic; negative; and (...) untested—and show how different concepts of disease impact on the disease and sickness judgements for these groups. The suggestion is that sickness judgements and social measures akin to those experienced during the current COVID-19 outbreak presuppose a concept of disease containing social harm as a component. We indicate the problems that arise when adopting this kind of disease concept beyond a state of emergency. (shrink)

How do people understand the concepts of mental health and disorder? The objective of this paper is to examine the impact of several factors on people’s judgments about whether a condition constitutes a mental disorder or a healthy state. Specifically, this study examines the impact of the source of the condition, its outcome, individual valuation (i.e., the value the individual attaches to the condition), and group valuation (i.e., the value the relevant group attaches to the condition). While we find that (...) people’s health and disorder judgments are driven by perceived dysfunction, we also find that health and disorder judgments are impacted differently by these factors. Health judgements are impacted by outcome and individual valuation, and disorder judgments are impacted by condition source. These results suggest that the folk concept of mental health is positive (i.e., mental health is more than the absence of mental disorder) and normativist (i.e., value judgments play a significant role in determining whether a condition counts as healthy), while the concept of mental disorder aligns with a naturalist perspective, at least to the extent that dysfunction plays an important role in categorizing a condition as a disorder. However, our finding that people’s dysfunction judgments are influenced by individual valuation and outcomes poses a strong challenge to naturalist accounts. To provide access to our supplementary data, an appendix has been included. (shrink)

This chapter examines the history of philosophy of psychology and philosophy of psychiatry as subfields of philosophy of science that emerged in the late twentieth and early twenty-first century. The chapter also surveys related literatures that developed in psychology and psychiatry. Philosophy of psychology (or philosophy of cognitive science) has been a well-established subfield of philosophy of mind since the 1990s and 2000s. This field of philosophy of psychology is narrowly focused on issues in cognitive psychology and cognitive science. Compared (...) to the thriving subfield of philosophy of cognitive science, there has been a lack of corresponding interest among philosophers of science in broader methodological questions about different paradigms and fields of study in psychology. These broader methodological questions about psychology have been addressed in the field of theoretical psychology, which is a subfield of psychology that materialized in the 1980s and 1990s. Philosophy of psychiatry emerged as a subfield of philosophy of science in the mid-2000s. Compared to philosophy of psychology, the philosophy of psychiatry literature in philosophy of science engaged with issues examined in an older and more interdisciplinary tradition of philosophy of psychiatry that developed after the 1960s. The participation of philosophers of science in the literature on theoretical psychology, by contrast, has been limited. (shrink)

This thesis is a philosophical examination of the explanatory roles of diagnoses in psychiatry. In medicine, diagnoses normally serve as causal explanations of patients’ symptoms. Given that psychiatry is a discipline whose practice is shaped by medical traditions, it is often implied that its diagnoses also serve such explanatory functions. This is evident in clinical texts that portray psychiatric diagnoses as referring to diseases that cause symptoms. However, there are problems which cast doubt on whether such portrayals are justified. I (...) address these problems and examine whether psychiatric diagnoses provide explanations of symptoms. The first problem is conceptual. In diagnostic manuals, psychiatric diagnoses are defined by their symptoms. This suggests that invoking them as explanations of the symptoms amounts to circularity. I argue that this can be resolved with an appropriate conceptual framework that captures the complex semantic values of diagnostic terms and their different uses in clinical discourse. I put forward such a framework based on two-dimensional semantics. The second problem is ontological. Empirical research suggests that diagnostic categories in psychiatry do not correspond to invariant causal types, but are associated with variable combinations of diverse causes that interact across biological, psychological, and social levels. Given this heterogeneity, I argue that psychiatric diagnoses fall short of paradigmatic cases of causal explanation, but that some can still provide other sorts of useful causal explanatory information. The original contribution of this thesis is the illumination of the conceptual relations between diagnoses and symptoms. This philosophical work is important, because it can be brought to valuable application in modifying psychiatric practice. (shrink)

Researchers attempting to explain and treat psychiatric disorders have long discussed the need for new disorder categories. A common proposal is to develop a causal classification system whereby psychiatric disorders are classified according to the causal processes that produce and sustain them. I evaluate the prospects for causal classification of psychiatric disorders. First, I motivate the need for a causal classification system of psychiatric disorders. Second, I introduce one framework for causal classification, the exemplar model. Third, I examine multiple forms (...) of causal complexity that the exemplar model must successfully navigate if it is to be a viable classification model for psychiatry. I argue that the exemplar model can handle some issues of causal complexity but not others. I conclude that psychiatry should utilize two models of classification, the exemplar model and the network model, because each fulfills some, but not all, of the purposes of classification systems. (shrink)

This dissertation in Theory of Practical Knowledge contends that depression is a disorder of the self. Using the existential-phenomenology of Maurice Merleau-Ponty, I argue that if we want to disclose the basic structure of depressed experience, then we must likewise disclose how selfexperience is inseparable from depressed experience. However, even though depression is a contemporary psychiatric category of illness, it is nevertheless a historically and heterogenous concept. To make sense of depression in the context of contemporary psychiatric practice, I show (...) that depression has historically been characterized by two broad models of causation; that is, a phenomenon that is causally explained by either a biological dysfunction or a psychological conflict. But this stark characterization is not limited just to history; by conducting qualitative interviews with psychiatric professionals, I illustrate how this causal dichotomy remains prevalent in contemporary psychiatric practice. On one hand, the clinicians report dissatisfaction with the depression diagnostic criteria (i.e. it is impersonal or vague), while on the other hand, the clinicians also recognize that a depression diagnosis is useful insofar as a diagnosis facilitates access to various resources associated with psychiatric care. Consequently, clinicians have developed a coping strategy that is witnessed in their empathetic desire to distance patients from their depression diagnosis, which led to statements such as, “you are not the problem, the problem is depression.” One consequence of this approach is that depression is artificially cleaved from the person who experiences depression, which subsequently means that depression is viewed to be something independent of oneself. Because I argue that depression and the self are mutually implicated, it is crucial to disseminate some of the most influential contemporary models of selfhood. I show that the brainbound, situated, psychological, and narrative model of self, all have respective strengths and weaknesses. But I also go beyond these models and characterize selfhood as a developmental phenomenon that is expressed as an embodied-style. This style reflects the way in which we establish perceptual contact with the otherness, without which there could be no self-experience. (shrink)