Current symptom-based DSM and ICD diagnostic criteria for mental disorders are prone to yielding false positives because they ignore the context of symptoms. This is often seen as a benign flaw because problems of living and emotional suffering, even if not true disorders, may benefit from support and treatment. However, diagnosis of a disorder in our society has many ramifications not only for treatment choice but for broader social reactions to the diagnosed individual. In particular, mental disorders impose a (...) sick role on individuals and place a burden upon them to change; thus, disorders decrease the level of respect and acceptance generally accorded to those with even annoying normal variations in traits and features. Thus, minimizing false positives is important to a pluralistic society. The harmful dysfunction analysis of disorder is used to diagnose the sources of likely false positives, and propose potential remedies to the current weaknesses in the validity of diagnostic criteria. (shrink)
Medical professionals, including mental health professionals, largely agree that moral judgment should be kept out of clinical settings. The rationale is simple: moral judgment has the capacity to impair clinical judgment in ways that could harm the patient. However, when the patient is suffering from a "Cluster B" personality disorder, keeping moral judgment out of the clinic might appear impossible, not only in practice but also in theory. For the diagnostic criteria associated with these particular disorders (Antisocial, Borderline, Histrionic, Narcissistic) (...) are expressed in overtly moral language. I consider three proposals for dealing with this problem. The first is to eliminate the Cluster B disorders from the DSM on the grounds that they are moral, rather than mental, disorders. The second is to replace the morally laden language of the diagnostic criteria with morally neutral language. The third is to disambiguate the notion of moral judgment so as to respect the distinction between having morally disvalued traits and having moral responsibility for those traits. Sensitivity to this distinction enables the clinician, at least in theory, to employ morally laden diagnostic criteria without adopting the sort of morally judgmental (and potentially harmful) attitude that results from the tacit presumption of moral responsibility. I argue against the first two proposals and in favor of the third. In doing so, I appeal to Grice's distinction between conventional and conversational implicature. I close with a few brief remarks on the irony of retaining overtly moral language in an ostensibly medical manual for the diagnosis of mental disorders. (shrink)
The public, mental health consumers, as well as mental health practitioners wonder about what kinds of values mental health professionals hold, and what kinds of values influence psychiatricdiagnosis. Are mental disorders socio-political, practical, or scientific concepts? Is psychiatricdiagnosis value-neutral? What role does the fundamental philosophical question "How should I live?" play in mental health care? In his carefully nuanced and exhaustively referenced monograph, psychiatrist and philosopher of psychiatry John Z. Sadler describes the manifold kinds (...) of values and value judgements involved in psychiatricdiagnosis and classification systems like the DSM. Professor Sadler takes the reader on a fascinating conceptual tour of the inner workings of psychiatricdiagnosis, considering the role of science, culture, sexuality, politics, gender, technology, human nature, patienthood, and professions in building his vision of a more humane psychiatric diagnostic process. (shrink)
Cultural congruence is the idea that to the extent a belief or experience is culturally shared it is not to feature in a diagnostic judgement, irrespective of its resemblance to psychiatric pathology. This rests on the argument that since deviation from norms is central to diagnosis, and since what counts as deviation is relative to context, assessing the degree of fit between mental states and cultural norms is crucial. Various problems beset the cultural congruence construct including impoverished definitions (...) of culture as religious, national or ethnic group and of congruence as validation by that group. This article attempts to address these shortcomings to arrive at a cogent construct. (shrink)
A psychiatricdiagnosis today is asked to serve many functions—clinical, research, medicolegal, delimiting insurance coverage, service planning, defining eligibility for state benefits , as well as providing rallying points for pressure groups and charities. These contexts require different notions of diagnosis to tackle the particular problem such a designation is meant to solve. In a number of instances, a ‘status’ definition is employed to tackle what is more appropriately seen as requiring a ‘functional’ approach . In these (...) instances, a diagnosis may play only a subsidiary role. Some examples are discussed: the criteria for involuntary treatment; the determination of criminal responsibility; and, assessing entitlements to state benefits. I suggest that the distinction between ‘status’ versus ‘function’ has not been given sufficient weight in discussions of diagnosis. It is in the functional domain that some of the problematic relationships between clinical psychiatry and the social institutions with which it rubs shoulders are played out. A status, signified by a diagnosis, has often been encumbered with demands for which it is poorly equipped. It is a reductive way of solving problems of management, allocation or disposal for which a functional approach should be given greater weight. (shrink)
The author analyses how debate over the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders has tended to privilege certain conceptions of psychiatricdiagnosis over others, as well as to polarise positions regarding psychiatricdiagnosis. The article aims to muddy the black and white tenor of many discussions regarding psychiatricdiagnosis by moving away from the preoccupation with diagnosis as classification and refocusing attention on diagnosis as a temporally and (...) spatially complex, as well as highly mediated process. The article draws on historical, sociological and first-person perspectives regarding psychiatricdiagnosis in order to emphasise the conceptual—and potentially ethical—benefits of ambivalence vis-à-vis the achievements and problems of psychiatricdiagnosis. (shrink)
In the conclusion to this multi-part article I first review the discussions carried out around the six essential questions in psychiatricdiagnosis – the position taken by Allen Frances on each question, the commentaries on the respective question along with Frances’ responses to the commentaries, and my own view of the multiple discussions. In this review I emphasize that the core question is the first – what is the nature of psychiatric illness – and that in some (...) manner all further questions follow from the first. Following this review I attempt to move the discussion forward, addressing the first question from the perspectives of natural kind analysis and complexity analysis. This reflection leads toward a view of psychiatric disorders – and future nosologies – as far more complex and uncertain than we have imagined. (shrink)
In the context of psychiatricdiagnosis, operationists claim that mental disorders are nothing more than the satisfying of objective diagnostic criteria, whereas realists claim that mental disorders are latent entities that are detected by applying those criteria. The implications of this distinction are substantial in actual clinical situations, such as in the co-occurrence of disorders that may interfere with one another's detection, or when patients falsify their symptoms. Realist and operationist conceptions of diagnosis may lead to different (...) clinical decisions in these situations, affecting treatment efficacy and ultimate patient outcomes. (shrink)
Flaws, biases, and ethical problems surrounding research and diagnosis may lead to inappropriate or inequitable treatments that exacerbate or fail to improve the misery that some individuals face due to their psychiatric conditions. Possible androcentric biases in the choice and definition of categories for diagnosis available in DSM-III-R may in turn influence the approaches of therapists to clients, particularly male therapists towards female clients. Androcentric bias in diagnosis, which may also be reflected in the values of (...) the psychiatrist, may lead to treatment regimens designed to make clients fit into roles, positions, and norms prescribed by a culture reflecting patriarchal values. Some acceptance of attempts by feminists to correct androcentrism are beginning to emerge in psychiatricdiagnosis. Keywords: androcentrism, bias, feminist, psychiatry of biology CiteULike Connotea Del.icio.us What's this? (shrink)
Psychiatricdiagnosis depends, centrally, on the transmission of patients’ knowledge of their experiences and symptoms to clinicians by testimony. In the case of non-native speakers, the need for linguistic interpretation raises significant practical problems. But determining the best practical approach depends on determining the best underlying model of both testimony and knowledge itself. Internalist models of knowledge have been influential since Descartes. But they cannot account for testimony. Since knowledge by testimony is possible, and forms the basis of (...)psychiatricdiagnosis, its very existence is a factor in support of an externalist model of knowledge in general. Internalist and externalist models of knowledge also suggest different ways of responding to the practical challenges of basing psychiatricdiagnosis on testimony. Thus the argument in favour of externalism also supports a potentially empirically testable hypothesis about interpretation of non-native speakers for accurate psychiatricdiagnosis: interpretation of non-English speakers should be as transparent and unhindered by specialised medical knowledge as possible. (shrink)
Psychiatrists diagnose mental illness in patients against a climate of opinion in which the value of diagnosis is questioned and non-medical formulations of the problems of psychiatric patients are put forward. Nevertheless the classic diagnostic terminology shows no sign of disappearing. The patients may find that a psychiatric diagnostic label is a stigma and has bad consequences. They may also object to standard methods of treatment. Given this situation the right of the patient to a full explanation (...) of the diagnosis and the rationale of the treatment offered seems to be incontrovertible. If this information were given to patients it would, in addition, help them to make sense out of their often puzzling experiences and indicate that fellow sufferers existed. (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 face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the (...) role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article will take up the first two questions. With the first question, invited commentators express a range of opinion regarding the nature of psychiatric disorders, loosely divided into a realist position that the diagnostic categories represent real diseases that we can accurately name and know with our perceptual abilities, a middle, nominalist position that psychiatric disorders do exist in the real world but that our diagnostic categories are constructs that may or may not accurately represent the disorders out there, and finally a purely constructivist position that the diagnostic categories are simply constructs with no evidence of psychiatric disorders in the real world. The second question again offers a range of opinion as to how we should define a mental or psychiatric disorder, including the possibility that we should not try to formulate a definition. The general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances. (shrink)
The two main psychiatric taxonomies set out codifications of psychiatric diagnoses via lists of symptoms with the aim of maximizing the reliability of diagnostic judgements. This approach has been criticized, however, for failing to capture the precise connection between diagnostic judgements and symptoms as detected by skilled clinicians. Assuming that this criticism is correct, this chapter offers two related accounts of why this might be so. First, skilled diagnostic judgement may be an exercise of tacit knowledge: a practical (...) skill the exercise of which requires the presence of the patient. Second, the conception of criteria implicit in the DSM and ICD is based on a mistaken view of how what people say and do connects to their mental states. On an alternative account, in an overall gestalt diagnostic judgement the various criteria are abstractions from a whole that directly expresses the underlying psychopathological state of patients or clients. (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)
Psychiatric abuse, such as we usually associate with practices in the former Soviet Union, is related not to the misuse of psychiatric diagnoses, but to the political power intrinsic to the social role of the psychiatrist in totalitarian and democratic societies alike. Some reflections are offered on the modern, therapeutic state's proclivity to treat adults as patients rather than citizens, disjoin rights from responsibilities, and thus corrupt the language of political-philosophical discourse.
In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the (...) role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part 1 of this article took up the first two questions. Part 2 took up the second two questions. Part 3 now deals with Questions 5 & 6. Question 5 confronts the issue of utility, whether the manual design of DSM-III and IV favors clinicians or researchers, and what that means for DSM-5. Our final question, Question 6, takes up a concluding issue, whether the acknowledged problems with the earlier DSMs warrants a significant overhaul of DSM-5 and future manuals. As in Parts 1 & 2 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances. (shrink)
British society is becoming increasingly culturally and linguistically diverse. This poses a major challenge to mental health services charged with the responsibility to work in ways that respect cultural and linguistic difference. In this paper we investigate the problems of interpretation in the diagnosis of depression using a thought experiment to demonstrate important features of language-games, an idea introduced by Ludwig Wittgenstein in his late work, Philosophical investigations. The thought experiment draws attention to the importance of culture and contexts (...) in understanding the meaning of particular utterances. This has implications not only for how we understand the role of interpreters in clinical settings, and who might best be suited to function in such a role, but more generally it draws attention to the importance of involving members of black minority ethnic (BME) communities in working alongside mainstream mental health services. We conclude that the involvement of BME community development workers inside, alongside and outside statutory services can potentially improve the quality of care for people from BME communities who use these services. (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)
This paper explores the factors that contribute to the degree of a mood disorder patient’s self- insight, defined here as her understanding of the particular contingencies of her life that are responsive to her personal identity, interpersonal relationships, illness symptoms, and the relationship between these three necessary components of her lived experience. I consider three factors: (i) the Diagnostic Statistical Manual of Mental Disorders (DSM), (ii) the DSM culture, and (iii) the cognitive architecture of the self. I argue that the (...) symptom-based descriptions of mood disorders which eliminate the subjective features of the patient’s illness experience, in conjunction with the features of the DSM-culture and the cognitive biases that guide the patient, contribute to the impoverishment of her self-insight. The resulting impoverished self-insight would prevent her from developing resourceful responses to her interpersonal problems. In analyzing how these factors combine to influence the patient’s self-insight, I distinguish the therapeutic impact of receiving a psychiatricdiagnosis, which facilitates patient’s clinical treatment, from its reflective impact, how the diagnosis informs the patient’s reflection on who she is, how her mental disorder is expressed, and how her interpersonal relationships proceed. I substantiate my argument by considering a patient’s memoir of psychopathology. (shrink)
This article argues that traditional models of diagnosis are incomplete in their reliance on a models of certainty that are no longer tenable in a postmodern world. Further, it argues that the current form of diagnosis, as applied to psychiatric and affective disorders, reduces patient agency and reinscribes the effects of biopower.
Using a “psychotherapeutic attitude”, as a criterion and measure of the psychiatrist’s involvement in clinical relationship (with the “trial identification” according to Fliess), some phenomenological and epistemological considerations are offered about diagnostic assessments, as a synchronic and diachronic recognising process. Inspired by Gehlen’s notion of “exoneration” (i.e., the reducing and focusing of the perceptive experience as applied to the wealth of the perceptible), this paper examines how the mind of a skilled diagnostician might work. Three levels are explored: firstly, “the (...) symbolic perception”, where perceptive/emotional data derived by “trial identification” and worked through during one’s professional experience, automatically selects wide fields of allusions (e.g., in the psychopathological prefigurations, suggested by the ‘‘contact’’); then, we consider the “exoneration” of scientific hypothesis, which allows the psychiatrist to give a scientifically recognisable form to the first diagnostic outlines gathered in the interpersonal communication; and thirdly, the holistic reflection is examined, which returns the doctor’s focus to the patient’s individual problems, after going through different and, at times, very high inference levels. It is not a question of phases, but of varyingly interwoven moments in the mind of the skilful clinician, which are based on the dialectics of identification/separation. (shrink)
In this chapter, our focus is the role played by notions of rationality in the diagnosis of mental disorders, and in the practice of overriding patient autonomy in psychiatry. We describe and evaluate different hypotheses concerning the relationship between rationality and diagnosis, raising questions about what features underpin psychiatric categories. These questions reinforce widely held concerns about the use of diagnosis as a justification for overriding autonomy, which have motivated a shift to mental incapacity as an (...) alternative justification. However, this approach too has recently been criticized from a mental disability rights perspective. Our analysis of the relationship between mental capacity and rationality is used to illuminate these concerns, and to investigate further the relationship between rationality and psychiatricdiagnosis. (shrink)
_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)
The World Psychiatric Association has emphasised the importance of idiographic understanding as a distinct component of comprehensive assessment but in introductions to the idea it is often assimilated to the notion of narrative judgement. This paper aims to distinguish between supposed idiographic and narrative judgement. Taking the former to mean a kind of individualised judgement, I argue that it has no place in psychiatry in part because it threatens psychiatric validity. Narrative judgement, by contrast, is a genuinely distinct (...) complement to criteriological diagnosis but it is, nevertheless, a special kind of general judgement and thus can possess validity. To argue this I first examine the origin of the distinction between idiographic and nomothetic in Windelband’s 1894 rectorial address. I argue that none of three ways of understanding that distinction is tenable. Windelband’s description of historical methods, as a practical example, does not articulate a genuine form of understanding. A metaphysical distinction between particulars and general kinds is guilty of subscribing to the Myth of the Given. A distinction based on an abstraction of essentially combined aspects of empirical judgement cannot underpin a distinct empirical method. Furthermore, idiographic elements understood as individualised judgements threaten the validity of psychiatricdiagnosis. In the final part I briefly describe some aspects of the logic of narrative judgements and argue that in the call for comprehensive diagnosis, narrative rather than idiographic elements have an important role. Importantly, however, whilst directed towards individual subjects, narratives are framed in intrinsically general concepts and thus can aspire to validity. (shrink)
Lennard Davis’s Biocultural Critique of the alleged certainty of diagnosis (Davis Journal of Bioethical Inquiry 7:227−235, 2010) makes errors of fact concerning psychiatric diagnostic categories, misunderstands the role of power in the therapeutic relationship, and provides an unsubstantiated and vague alternative to the management of psychological distress via a conceptually outdated model of the relationships between physical and psychological disease and illness. This response demonstrates that diagnostic knowledge vouchsafes legitimate power to physicians, and via them relief to patients (...) who suffer from psychological distress. The history of medicine and psychiatry demonstrates that psychiatricdiagnosis shares many features with physical diagnosis, while there is also reason to believe that the two types will continue to be distinct in some respects. Diagnostic categories in psychological medicine, like those in physical medicine, are provisional, probabilistic, and often uncertain. These features do not detract from the dependence on diagnosis of therapeutic efficacy in both domains. (shrink)
Although diagnosis is integral to the theory and practice of psychiatry, social scientists have not developed a comprehensive approach to diagnosis. This paper presents a preliminary outline of the issues which a sociology of diagnosis should integrate. These include bias and social control in psychiatricdiagnosis, diagnosis as part of a new extension of the biopsychiatric medical model, and flaws in contemporary diagnostic categorization. These issues are then viewed in terms of professional practice styles, (...) diagnostic biases, psychiatry's professional dominance over the mental health field, and psychiatric hegemony over the clinical interaction with patients. (shrink)
In this paper I investigate the topic of paranoid atmospheres. This subject is especially of interest with respect to persons who are deluded, and also, I will demonstrate, sheds light upon the psychiatrist's "gaze" and knowledge of delusions. In my argument I will follow a path initially outlined by Karl Jaspers (1883-1969): modern psychiatricdiagnosis of delusions is a diagnosis of form and not content. Jaspers' emphasis on the form of delusions enables psychiatrists to be self-critical about (...) their professional knowledge and, consequently, prevent the development of dogmatic attitudes. In accord with Jaspers, my argument will focus on the basic structure of delusions and highlight the difference between delusional realities and non-delusional realities, a difference that follows from the possibility of self-criticism of one's own conscious and explicit convictions. I will demonstrate the importance of self-criticism with regard to paranoid atmospheres and also to psychiatric knowledge. In this manner, an understanding of delusions as lived experience will be developed, which argues that an escalation of the influence of delusional convictions, resulting in a profoundly paranoid atmosphere, is most problematic for the deluded person. To acknowledge this insight mirrors the need for a self-critique of psychiatric discourse, encourages an empathic and respectful relationship between professionals and deluded patients, and enables deluded persons to restrict their paranoid atmosphere. It is the main conclusion of my paper that a deluded person cannot do (with respect to his delusional convictions) what a psychiatrist must do (with respect to his psychiatric knowledge and his own existential convictions) in order to prevent a profoundly paranoid atmosphere in their relationship: be self-critical. (shrink)
The network approach to psychiatric phenomena has the potential to clarify and enhance psychiatricdiagnosis and classification. However, its generally well-justified anti-essentialism views psychiatric disorders as invariably fuzzy and arbitrary, and overlooks the likelihood that the domain includes some latent categories. Network models misrepresent these categories, and fail to recognize that some comorbidity may represent valid co-occurrence of discrete conditions.
Psychiatric researchers typically assume that the modelling of psychiatric symptoms is not influenced by psychiatric categories; symptoms are modelled and then grouped into a psychiatric category. I highlight this primarily through analysing research domain criteria. RDoC’s importance makes it worth scrutinizing, and this assessment also serves as a case study with relevance for other areas of psychiatry. RDoC takes inadequacies of existing psychiatric categories as holding back causal investigation. Consequently, RDoC aims to circumnavigate existing (...) class='Hi'>psychiatric categories by directly investigating the causal basis of symptoms. The unique methodological approach of RDoC exploits the supposed lack of influence of psychiatric categories on symptom modelling, taking psychiatric symptoms as the same regardless of which psychiatric category is employed or if no psychiatric category is employed. But this supposition is not always true. I will show how psychiatric categories can influence symptom modelling, whereby identical behaviours can be considered as different symptoms based on an individual’s psychiatricdiagnosis. If the modelling of symptoms is influenced by psychiatric categories, then psychiatric categories will still play a role, a situation which RDoC researchers explicitly aim to avoid. I discuss four ways RDoC could address this issue. This issue also has important implications for factor analysis, cluster analysis, modifying psychiatric categories, and symptom based approaches. (shrink)
This paper will consider the right not to know in the context of psychiatric disorders. It will outline the arguments for and against acquiring knowledge about the results of genetic testing for conditions such as breast cancer and Huntington’s disease, and examine whether similar considerations apply to disclosing to clients the results of genetic testing for psychiatric disorders such as depression and Alzheimer’s disease. The right not to know will also be examined in the context of the (...) class='Hi'>diagnosis of psychiatric disorders that are associated with stigma or for which there is no effective treatment. (shrink)
Psychiatric treatment and diagnosis rests upon a richer conception of normativity than, for example, cognitive neuropsychology. This paper explores the role that considerations of rationality can play in defining this richer conception of normativity. It distinguishes two types of rationality and considers how each type can break down in different ways in delusional psychiatric disorders.
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)
The main objective in this chapter is to examine the role of judgments of rationality in the current understanding of psychiatric disorders. To what extent are the criteria for classification and diagnosis independent of judgments of rationality? The typical symptoms of many psychiatric disorders are described as instances of epistemic, procedural, or emotional irrationality, and references to such forms of irrationality are frequently made in the current classificatory and diagnostic criteria for schizophrenia, dementia, depression, and personality disorders. (...) That said, the chapter defend the view that irrationality is neither necessary nor sufficient for a behavior to be characterized as symptomatic of a psychiatric disorder. (shrink)
Psychiatrists are frequently called upon to make assessments of the rationality or irrationality of persons for a variety of medical-legal purposes. A key category is that of evaluations of a patient's capacity to grant informed consent for a medical procedure. A diagnosis of mental illness is neither a necessary nor a sufficient condition for a finding of incompetence. The notion of competency to grant consent, which is a mixed psychiatric-legal concept, shares some features with philosophical conceptions of rationality, (...) but differs from them in a number of important respects. This article describes the actual practice of psychiatrists when making such judgments, along with the standards of competency they employ. A comparison is made between those notions of competency and predominant philosophical conceptions of rationality. (shrink)
The development of the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders—the DSM-5—has reenergised and driven further forward critical discourse about the place and role of diagnosis in mental health. The DSM-5 has attracted considerable criticism, not least about its role in processes of medicalisation. This paper suggests the need for a sociology of psychiatric critique. Sociological analysis can help map fields of contention, and cast fresh light on the assumptions and (...) nuances of debate around the DSM-5; it underscores the importance of diagnosis to the governance of social and clinical life, as well as the wider discourses critical commentaries connect with and are activated by. More normatively, a sociology of critique can indicate which interests and values are structuring the dialogues being articulated, and just how diverse clinical opinion regarding the DSM can actually be. This has implications for the considerations of health services and policy decision-makers who might look to such debates for guidance. (shrink)
Psychiatric Medicine has been accused justly of making its diagnoses on the patient's report of symptoms and the physician's subjective observations of the patient. The main problem has been the lack of reliable data compounded by the stigma of a mental diagnosis. More recently, third-party pressures have become an added threat to objectivity. New knowledge of brain function, especially neurotransmitters, and more specific and effective medication have made the need for accurate diagnoses more acute. Psychiatry has responded by (...) frequent and often controversial changes in its diagnostic criteria. Much of the controversy stems from a lack of accurate measurements to validate the diagnoses, thereby allowing for differences of opinion of a highly subjective nature. The problem is complicated by the chronic, but irrational, belief that there is a separation between mental and somatic illness. Keywords: calibration, diagnoses, objective vs. subjective, stigma, third-party CiteULike Connotea Del.icio.us What's this? (shrink)
Psychiatric treatment and diagnosis rests upon a richer conception of normativity than, for example, cognitive neuropsychology. This paper explores the role that considerations of rationality can play in defining this richer conception of normativity. It distinguishes two types of rationality and considers how each type can break down in different ways in delusional psychiatric disorders.