It has been argued that some unremitting forms of grief, commonly labeled as complicated grief, pose a serious threat to the well-being and life of the mourner and may require clinical attention (Lichtenthal et al., 2004; Zisook et al., 2010). One central issue in this debate is whether and how we could draw a divide between uncomplicated and complicated grief to avoid, on the one hand, the medicalization of appropriate grief responses, and on the other hand, to provide (...) help to those who suffer from complicated grief. In this paper I show that a phenomenological approach can help with this task. First, I present Ratcliffe’s (2017) and Fuchs’ (2018) phenomenological analyses of typical grief responses. Then I argue that a promising way to draw a divide between uncomplicated and complicated grief is to look for the presence of reintegration processes geared towards establishing a new relation with the deceased. (shrink)

Categorization-based diagnosis, which endeavors to be consistent with the third-person, objective measures of science, is not always adequate with respect to problems concerning diagnostic accuracy, demarcation problems when there are comorbidities, well-documented problems of symptom amplification, and complications of stigmatization and looping effects. While psychiatric categories have proved useful and convenient for clinicians in identifying a recognizable constellation of symptoms typical for a particular disorder for the purposes of communication and eligibility for treatment regimes, the reification of these (...) categories has without doubt had negative consequences for the patient and also for the general understanding of psychiatric disorders. We argue that a complementary, integrated framework that focuses on descriptive symptom-based classifications (drawing on phenomenological interview methods and narrative) combined with a more comprehensive conception of the human subject (found in the pattern theory of self), can not only offer a solution to some of the vexed issues of psychiatric diagnosis but also support more efficacious therapeutic interventions. (shrink)

Recent editions of diagnostic manuals in psychiatry have focused on providing quick and efficient operationalized criteria. Notwithstanding the genuine value of these classifications, many psychiatrists have argued that the operationalization approach does not sufficiently accommodate the rich and complex domain of patients’ experiences that is crucial for clinical reasoning in psychiatry. How can we increase the role of phenomenology in the process of diagnostic reasoning in psychiatry? I argue that this could be done by adopting a clinical staging approach in (...) diagnostic reasoning in psychiatry. The approach has the resources to include the progressive nature of patients’ experiences to a much greater degree than is currently practiced. It can address the recent plea for increasing the role of phenomenology in psychiatric diagnosis by offering a model for clinical reasoning that goes beyond the operationalized, static criteria of diagnostic manuals, without depriving us of their benefits. (shrink)

The World Health Organization states that depression is the leading cause of disability worldwide, and predicts that by 2030 the epidemic of depression raging across the world will be the single biggest contributor to the overall burden of disease of all health conditions. Yet this gloomy picture masks a number of paradoxes concerning the diagnosis and cultural interpretation of depression that appear to challenge the claimed prevalence rates on which it is based. This book's essays by some of the (...) world's leading researchers and scholars on depression explores these anomalies in detail from multidisciplinary and multicultural perspectives, and in doing so reshapes the debate on the nature of depression that is currently under way in the US and abroad. At the book's core is the exploration from the multiple perspectives of a key dilemma: is the epidemic of depression real or is it just apparent? In particular, could it be the result of criteria laid down in the official American classification system of mental disorders, the DSM, interacting with cultural changes to reshape our view of melancholy, pathologizing what were formerly normal symptoms of grief or intense sadness? The debate over the DSM's conception of depression has an international relevance, with the WHO's upcoming revisions to its International Classification of Diseases requiring coordination with the DSM. This collection of perspectives has an unprecedented international dimension, as scholars from Europe and around the world join US academics to explore a central and controversial element of contemporary psychiatric diagnosis - and one that has enormous practical implications for the future of mental health care and how we view our emotions. The book's accessible essays will make it useful to scholars, practitioners, and students across a wide range of disciplines. (shrink)

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

In the present article, we aimed at describing the diagnostic process in Psychiatry through a phenomenological perspective. We have identified 4 core concepts which may represent the joints of a phenomenologically oriented diagnosis. The "tightrope walking" attitude refers to the psychiatrist's ability to swing between 2 different and sometimes contrasting tendencies (e.g., engagement and disengagement). The "holistic experience" includes all those intuitive, nonverbal, and pre-thematic elements that emerge in the early stages of the clinical encounter as an emanation of (...) the atmospheric quality of the intersubjective space. The "co-construction of symptoms" regards the hermeneutic process behind psychiatric symptoms, involving both the patient as a self-interpreting agent and the clinician as a translator of his/her experience. Finally, by the "evolving typification" we mean that the closer the relationship becomes with the patient, the more specific and nuanced becomes the typification behind psychiatric diagnosis. Each of these concepts will be accompanied by an extract from a clinical case deriving from one of the authors' most recent clinical experiences. (shrink)

After the publication of third edition of the Diagnostic and Statistical Manual of Mental Disorders in 1980, psychiatry no longer characterized psychological problems as 'reactions,' which seemed to assume unproven psychoanalytically derived explanations, and referred to them instead as 'disorders,' which, it was thought, could be identified phenomenologically and without theoretical 'presuppositions.' Since then, psychiatrists have typically made diagnoses without reflecting on the fact that any categorization, including psychiatric diagnosis, exists within a framework of beliefs and practices and (...) will, therefore, have implications and consequences. The fact of making a diagnosis, the act of doing so... (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)

his article develops a set of recommendations for the psychiatric and medical community in the treatment of mental disorders in response to the recently published fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, that is, DSM-5. We focus primarily on the limitations of the DSM-5 in its individuation of Complicated Grief, which can be diagnosed as Major Depression under its new criteria, and Post-Traumatic Stress Disorder (PTSD). We argue that the hyponarrativity of the descriptions of (...) these disorders in the DSM-5, defined as the abstraction of the illness categories from the particular life contingencies and personal identity of the patient (e.g., age, race, gender, socio-economic status), constrains the DSM-5's usefulness in the development of psychotherapeutic approaches in the treatment of mental disorders. While the DSM-5 is useful in some scientific and administrative contexts, the DSM's hyponarrativity is problematic, we argue, given that the DSMs are designed to be useful guides for not only scientific research, but also for the education of medical practitioners and for treatment development. our goal therefore is to offer suggestions for mental health practitioners in using the DSM-5, so that they can avoid or eliminate the problems that may stem from the limitations of hyponarrativity. When such problems are eliminated, we believe that effective psychotherapeutic strategies can be developed, which would be successful in repairing the very relationships that are strained in mental disorder: the patient's relationship to herself, her physical environment, and her social environment. (shrink)

Background: COVID-19 has taken many lives worldwide and due to this, millions of persons are in grief. When the grief process lasts longer than 6 months, the person is in risk of developing Complicated Grief Disorder. The CGD is related to serious health consequences. To reduce the probability of developing CGD a preventive intervention could be applied. In developing countries like Mexico, the psychological services are scarce, self-applied interventions could provide support to solve this problem and reduce the health (...) impact even after the pandemic has already finished.Aims: To design and implement a self-applied intervention composed of 12 modules focused on the decrease of the risk of developing CGD, and increasing the life quality, and as a secondary objective to reduce the symptomatology of anxiety, depression, and increase of sleep quality. The Intervention Duelo COVID follows the principles of User Experience and is designed according to the needs and desires of a sample of the objective participants, to increase the adherence to the self-applied intervention, considered one of the main weaknesses of online interventions.Methods: A Randomized Controlled Trial will be conducted from the 22nd of December of 2020 to the first of June 2021. The participants will be assigned to an intervention with elements of Cognitive Behavioral Therapy, Acceptance and Commitment Therapy, Mindfulness and Positive Psychology. The control group will be a wait-list condition, that will receive the intervention 1.5–2 months after the pre-measurement were taken. The Power Size Calculation conducted through G*Power indicated the need for a total of 42 participants, which will be divided by 21 participants in each group. The platform will be delivered through responsive design assuring with this that the intervention will adapt to the screen size of cellphones, tablets, and computers.Ethics and Dissemination: The study counts with the approval of the Research Ethics Committee of the Autonomous University of Ciudad Juárez, México, and it is registered in Clinical Trials. The article is sent and registered in clinical trials before the recruitment started. The results will be reported in future conferences, scientific publications, and media. (shrink)

Summary Leading scholars offer perspectives from the philosophy of science on the crisis in psychiatric research that exploded after the publication of DSM-5. -/- Psychiatry and mental health research is in crisis, with tensions between psychiatry's clinical and research aims and controversies over diagnosis, treatment, and scientific constructs for studying mental disorders. At the center of these controversies is the Diagnostic and Statistical Manual of Mental Disorders (DSM), which—especially after the publication of DSM-5—many have found seriously flawed as (...) a guide for research. This book addresses the crisis and the associated “extraordinary science” (Thomas Kuhn's term for scientific research during a state of crisis) from the perspective of philosophy of science. The goal is to help reconcile the competing claims of science and phenomenology within psychiatry and to offer new insights for the philosophy of science. -/- The contributors discuss the epistemological origins of the current crisis, the nature of evidence in psychiatric research, and the National Institute for Mental Health's Research Domain Criteria project. They consider particular research practices in psychiatry—computational, personalized, mechanistic, and user-led—and the specific categories of schizophrenia, depressive disorder, and bipolar disorder. Finally, they examine the DSM's dubious practice of pathologizing normality. (shrink)

In this chapter, I provide an overview of phenomenological approaches to psychiatric classification. My aim is to encourage and facilitate philosophical debate over the best ways to classify psychiatric disorders. First, I articulate phenomenological critiques of the dominant approach to classification and diagnosis—i.e., the operational approach employed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the International Classification of Diseases (ICD-10). Second, I describe the type or typification approach to psychiatric classification, which I (...) distinguish into three different versions: ideal types, essential types, and prototypes. I argue that despite their occasional conflation in the contemporary literature, there are important distinctions among these approaches. Third, I outline a new phenomenological-dimensional approach. I show how this approach, which starts from basic dimensions of human existence, allows us to investigate the full range of psychopathological conditions without accepting the validity of current diagnostic categories. (shrink)

The world as we currently know it is troubled by climate change, leaving a marked trace in our affective landscape, for example, in the form of shame, anger, and depression. This affective landscape needs further philosophical exploration, and in this paper I use analyses by Aristotle, Heidegger, and Butler to discuss anxiety and grief. I focus on these two affects because they a) often collaborate in times of ecological destruction, and b) can be distinguished in terms of short-term intentional “emotions” (...) and as long-term, atmospheric “moods.” Due to their temporal and atmospheric flexibility, these affects gain particular traction in relating to the deep-time timescale of the Anthropocene. At the end of the paper, I discuss trust, since the affective constellation of long-term atmospheric anxiety and grief can become especially productive when combined with the safety of trust, in that such constellation may enable constructive transformations building environmentally sustainable futures. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Priming and Narrative Habits in the Phenomenological InterviewReflections on a Study of Tourette SyndromeThe author reports no conflicts of interest.In "Dimensions, Not Types: On the Phenomenology of Premonitory Urges in Tourette Syndrome," Lisa Curtis-Wendlandt and Jack Reynolds provide new insights into some of the experiences characteristic of Tourette syndrome (TS). Their study is an excellent example of applied phenomenology (Burch, 2021), combining philosophy and qualitative research methods to illuminate (...) experiences that have often been mischaracterized in the existing literature. In their study, they focus on what is commonly referred to as a "premonitory urge" (PU): the "anticipatory urge that is often thought to precede the onset of the motor and phonic tics that are part of Tourette Syndrome" (Curtis-Wendlandt & Reynolds, 2024, p. 26). They ask not only whether PU is a necessary feature of TS, but also whether the very concept of PU accurately portrays the experiences and behaviors that it's intended to refer to. They point out that existing scales used to assess PU, for example, seem to implicitly narrow the relevant experiences by assuming that they are a) always negative and b) always internal, or inwardly focused (Curtis-Wendlandt & Reynolds, 2024, 26). Curtis-Wendlandt and Reynolds question these in-built assumptions about PU, suggesting that they may provide an overly narrow depiction that misses the genuine diversity of experiences that precede the onset of a motor or phonic tic.To explore these phenomena in more detail, they conducted a study intended to elicit fresh descriptions of these experiences. They interviewed 12 teenagers with a diagnosis of TS about their experiences of ticcing and tic suppression. Using the micro-phenomenological method (Petitmengin, 2006), they asked participants to reflect on a specific tic or tic suppression event and to recall the event in detail. Throughout the interview, [End Page 43] they asked open-ended questions about sensory, cognitive, or affective experiences surrounding the event. Through these interviews, they were able to generate rich descriptions of these experiences and investigate how these descriptions differed from standard accounts in the existing literature.Curtis-Wendlandt and Reynolds provide a detailed account of how they designed their phenomenological study, both philosophically and empirically. However, there is an important aspect of their method that they discuss only in a cursory or implicit way, which is what I want to focus on here. Throughout their study, they were concerned that participants might simply parrot back well-worn medicalized characterizations of PU. Such characterizations risk simplifying or even occluding key aspects of the participants' experiences that might be difficult to reflect upon or describe. However, despite stressing the importance of eliciting fresh descriptions, Curtis-Wendlandt and Reynolds provide only glimpses of how the interviews actually unfolded and what kinds of techniques they used to elicit these descriptions.In my experience, it is quite common to hear phenomenological psychologists and psychiatrists express concern that people may simply repeat common psychiatric or medicalized characterizations of their condition, rather than genuinely reflect upon and describe their first-person experiences. The philosophical assumption is that we all fall back on culturally sedimented language and terminology when describing our experiences. Someone who has spent extended periods of time interacting with psychiatrists and other healthcare professionals, for example, is likely to have picked up common ways of describing their condition—ways that may have helped them receive a diagnosis or obtain treatment. There is nothing inherently wrong with falling into these culturally sedimented characterizations. They facilitate everyday communication through a shared language and terminology. But phenomenologists are often concerned that this kind of culturally sedimented language covers over or obscures the phenomenon or experience they are trying to investigate. For example, if a psychiatrist has often described their patient's depressed mood as "sadness," then that patient may be likely to self-describe their mood as sadness in an interview setting. It might, in fact, be the case that their mood is best described as sadness. But it could also be the case that their mood would be more accurately described as, for instance, a sense of emptiness or feeling deep despair. The challenge is therefore to know whether someone's self-description is... (shrink)

e understanding of the etiology and pathogenesis of these psyc hiatric disorders such as schizophrenia and depression is still n ot completely clear. At present, there is a lack of objective ne urobiological markers that can be used in clinical routine work such as clinical diagnosis, curative effect evaluation and progn osis evaluation of psychiatric disorders. Therefore, it is of great clinical significance to find biomarkers to improve the diagnos is level and evaluate the curative effect. Electroencephalogram (EEG) (...) is a non-invasive technique to record the potential activi ty of biological brain, through which researchers can analyze th e mechanisms underlying psychiatric disorders. In addition, mac hine learning can be used to further verify the role of these el ectrophysiological indicators in clinical diagnosis and curative e ffect evaluation of psychiatric disorders. The goal of this resear ch topic is to advance research on neurobiomarkers and EEG/ MEG-based diagnostic methods for mental disorders. We hope to conduct in-depth research on the pathogenesis and diagnostic measures of mental diseases such as schizophrenia and depressi ve disorder through EEG/MEG, in order to improve the perfor mance of artificial intelligence for mental diseases diagnosing.Under this research theme, the following is a brief overview of nine published articles, which respectively studied the diagnosis, The work in this special issue may fall into three categories of research: 1) method... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Husserlian Phenomenology and the Treatment of DepressionCommentary and CritiqueMarilyn Nissim-Sabat (bio)KeywordsHusserl, phenomenology, psychotherapy, drug therapyProfessor Hadreas begins his interesting and challenging essay by saying that, "This paper is concerned with a model of self-awareness which fits the testimony of subjects' reactions to selective serotonin reuptake inhibitors (SSRIs), of which fluoxetine (Prozac, Lilly, Indianapolis, IN) is probably the best known" (2010, 43). Several important features of Dr. Hadreas' approach can (...) be inferred from this statement. Most important, the verbatim testimony of subjects regarding their states of self-awareness is analyzed and interpreted for its compatibility with three philosophical models of self-awareness: Empiricism, rationalism, and Husserlian phenomenology. This is the methodology through which the author aims to show that one of the three models is more adequate than the others as a model of the self-awareness of the subjects, and that model is that of Husserlian phenomenology (hereinafter, phenomenology, with the understanding that only phenomenology according to Husserl is intended by both Dr. Hadreas and myself). In formulating this as the aim of his paper and his research, Dr. Hadreas has taken on an extremely difficult task.In general, attempts to show that any philosophical stance bears directly and immediately on the understanding of patients' symptoms, as well as on both theoretical and therapeutic work with people with mental disorders, is, owing to the ostensible gap in levels of conceptualization and systematicity, that is, the theory/praxis divide ostensibly separating the two realms, extraordinarily difficult. The task is rendered even more difficult in work like that of Prof. Hadreas,' in which, I believe, the researcher does not want to "apply" philosophy parasitically, as if research into psychiatric phenomena in relation to philosophy is just a matter of cannibalizing philosophy for self-justification, or vice versa; rather, Hadreas wants to preserve the integrity of both research into the phenomenology of psychiatric disorders and of [End Page 53] the philosophical perspective that may improve understanding of those disorders. In undertaking an effort along these lines, Hadreas breaks new ground.In particular, for this commentator, bringing Husserlian phenomenology to bear on these issues is particularly gratifying. Moreover, and most important, Hadreas bases his critique of classical empiricist and rationalist models of self-awareness on bringing to the fore Husserl's views on pre-reflective consciousness. This is extremely important for, as Dan Zahavi, noted Husserlian phenomenologist and philosopher of the phenomenology–psychiatry interface, points out, not only in the book cited by Hadreas but in a more recent article (Zahavi 2003), Husserl's notion of self-awareness has been critiqued by many who claim that he lacked a notion of pre-reflective consciousness. Indeed, Zahavi's (2003) work in this area quite effectively refutes these claims, and he does so by drawing on a large body of evidence from Husserl's posthumous writings. Thus, Hadreas is to be congratulated for using Husserl's long-neglected notion of pre-reflective consciousness as a means of approaching phenomenologically the testimony of patients who discussed changes in their self-awareness owing to their experiences with SSRI medications, chiefly fluoxetine. However, it is just because I share with Hadreas the conviction that Husserlian phenomenology is the best philosophical approach to understanding, and indeed, possibly improving the treatment of mental disorders, that I think it is vital to raise some questions regarding Hadreas' approach.My first critical comment is this: Hadreas' aim in writing his paper is unclear in a way that calls his project into question. In the conclusion of his paper, he indicates that his findings can enable psychiatrists to determine which patients are more likely to experience "SSRI cures." Given this, it would seem that his purpose in introducing Husserlian phenomenology is to facilitate this goal. Those subjects, he finds (based on his phenomenological analysis of the subjects' own testimony), who "have lived enough of life to have formed, for better or worse, an abiding empirical ego" are more likely to be "good responders" to SSRIs. It would seem, then, that this finding would aid psychiatrists in evaluating patients who have been treated, or who might be treated, with SSRIs. This, then, if correct, would be a considerable... (shrink)

This article discusses the way how change in depressed patients included in clinical trials was both conceptualized and measured in the 1970s to decide on the efficacy of the first candidate drugs for the treatment of depression. Understanding how this issue was resolved is of major interest as the protocol designed to distinguish the diagnosis of the depressive syndrome from the measurement of its evolution over time built the contours of the methodological device to which the whole of standardized (...) evaluation in psychiatry has since referred. This paper draws on the debates in nascent psychopharmacology in both the United States and Europe and examines the protocols and findings of the research programs on depression the National Institute of Mental Health (NIMH) has developed in the United States at the same time, as well as on the writings of the main authors of the standardized evaluation. This investigation suggests that measurement of patients’ improvement could not be characterized on the basis of psychiatric inventories that were not well-suited to quantification, nor on the basis of psychometric tests which were intended for the evaluation of psychological invariants. This is why the answer given to the characterization of change in depression under therapy rather reveals a syncretism both conceptual and technical, mixing classificatory and psychometric traditions, a syncretism that the distinction endorsed by the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition,between syndromes and personality disorders no longer allows us to perceive. (shrink)

The philosophical and scientific foundations of psychiatry -- Psychiatric diagnosis and the DSM debates -- Grief, depression and the bereavement controversy -- Psychiatry in crisis -- Psychiatry and humane values.

In lieu of an abstract, here is a brief excerpt of the content:Mental Disorder and Moral Responsibility:Disorders of Personhood as Harmful Dysfunctions, With Special Reference to AlcoholismJerome C. Wakefield (bio)Keywordsalcohol dependence, philosophy of psychiatry, mental disorder, harmful dysfunction, psychiatric diagnosis, person, moral responsibilityIn his paper, Ethical Decisions in the Classification of Mental Conditions as Mental Illness, Craig Edwards grapples with a profound problem: why is it that when we classify a mental condition as a mental disorder, that tends (...) to take the condition out of the sphere of moral responsibility or virtuousness of character? For example, it is not uncommon when someone commits suicide and the question is raised as to why he or she did it, that instead of a reason or character trait that would place the act within a moral calculus, one is offered the explanation "she was clinically depressed" or "he was bipolar," and this tends to terminate discussion and make reasons and moral evaluation superfluous. Why does such a comment have that effect?As Edwards notes, this can get complicated as the moral and the disordered interact. Certainly people are sometimes morally responsible for acting on their disordered impulses (as in pedophilia), and they are responsible for putting themselves in the way of disorder, as when someone imbibes in a way likely to lead to alcoholism. But at the normal/disorder divide, there seems to be a consistent lifting of some responsibility, reflecting the application of the sick role. For example, the rough equivalent of our current category of post-traumatic stress disorder (PTSD) was recognized as a disorder in earlier wars ("shell shock," "war neurosis"), but often considered an expression of cowardice; the cowardice was morally evaluable as a failure of virtue (even if, like many personality traits, being a coward is not within the person's direct voluntary control) and led to contempt for those with PTSD, but nonetheless—except in cases thought to be malingering—the PTSD that resulted constituted a disorder for which the individual was [End Page 91] not in the same direct sense blameworthy. This moral shift requires explanation.This topic also has important social ramifications. Relief from responsibility may sound like a good thing, and it is trumpeted by mental health advocates as a reason for supporting the classification of many conditions as disorders. But as Edwards is aware, it is a two-edged sword. Disordered status may allow escape from censure and offer the protections of the sick role, but it also changes the relationship of the agent to his or her own actions and imposes the responsibility of the sick role on the individual to attempt to change ("get better"). The sick role allows for no defense of an idiosyncrasy based on normal variation ("It takes all kinds…") or the individual's eccentric vision or steadfast integrity, for that vision or sense of integrity are now seen as pathological and not morally legitimate. The individual is subjected to endless entreaties to seek help and it is implied that not to do so is irresponsible, so that a decision to embrace one's nature and remain as one is becomes illegitimate. Moreover, the sick role allows for no explanation in terms of the individual's normal defensive response to unjust, deprived, or challenging social or environmental circumstances, thus weakening the motives for social change rather than individual intervention.In sum, there is an inevitable sense in which being placed in the sick role inherently stigmatizes the "sick" condition in virtue of the special moral attitudes extended to the disordered. Cultures can thus easily exploit the sick role and its much-touted relief from responsibility to extend the reach of social control processes. This is one reason why the distinction between disorder and non-disorder is so important, and why it is crucial to identify when non-disordered conditions are mislabeled as disorders—as when, for example, psychiatry gets it wrong about the distinction between normal and disordered sadness (Horwitz and Wakefield, 2007). Such overpathologization can redefine the boundaries of our moral universe on mistaken grounds.Edwards offers two provocative answers—not entirely at ease with each other—to the question of why mental disorders relieve the patient from moral responsibility: (1) mental disorders are... (shrink)

In this paper, I examine recent phenomenological research on both depressive and manic episodes, with the intention of showing how phenomenologically oriented studies can help us overcome the apparently paradoxical nature of mixed states. First, I argue that some of the symptoms included in the diagnostic criteria for depressive and manic episodes in the DSM-5 are not actually essential features of these episodes. Second, I reconsider the category of major depressive disorder (MDD) from the perspective of phenomenological psychopathology, arguing that (...) severe depressive episodes should not be characterized by any particular moods (such as sadness, hopelessness, or guilt), and should instead be characterized by a diminished capacity for finding ourselves situated in and attuned to the world at all. In other words, the affective dimension of depression should be characterized as a change in the way we have moods, not as a change from one kind of mood to another. Third, I turn to mania, arguing that manic episodes, taken as the opposite of depressive episodes, should be characterized not by any particular moods (such as euphoria, grandiosity, or even irritability), but should instead be characterized by an enhanced or heightened capacity for finding ourselves situated in and attuned to the world. In other words, the affective dimension of mania, like the affective dimension of depression, should be understood as a change in the way we have moods, not as a change from one kind of mood to another. Fourth, I return to the phenomenon of mixed states and argue that the affective dimension of depression and mania, when conceived along the phenomenological lines I set forth in the previous sections, dissolves the paradox of mixed states by showing that the essential characteristics of depression and mania cannot and do not coincide. Many cases of mixed states are diagnosed because moods that we take to be essential features of either depression or mania arise within the context of what is considered to be the opposite kind of episode (e.g. dysphoria, typically associated with depression, often arises in what is otherwise considered a manic state). However, if we conceive of the affective dimension of depression as a decrease in the degree to which one is situated in and attune to the world through moods, and the affective dimension of mania as an increase in the degree to which one is situated in and attuned to the world through moods, then the particular mood one finds oneself in is simply irrelevant to the diagnosis of either depression or mania. As a result, the manifestation of any particular moods in what otherwise seems to be a pure manic or depressive episode does not constitute a mixed state. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Mourning or MelancholiaJ. Melvin Woody (bio)Keywords“objective correlative”, depression, grief, cognitive-affective dissonanceIn a celebrated and controversial critical essay, T.S. Eliot faults Shakespeare's Hamlet on the grounds that the playwright has not provided sufficient “objective correlative” for the moods of his melancholy Dane. For lack of the “complete adequacy of the external to the emotion” that he finds in Shakespeare's other tragedies, Eliot judges that “the play is almost certainly an (...) artistic failure” (Eliot 1921, 101, 98). Dr. Bailey's explanation of Colin's melancholy provokes parallel critical reflections. When his initial expectation that he will discover the cause of depression in traumatic battle experiences in Iraq proves groundless, he finds that cause, instead, in the very absence of traumatic experiences. I cannot but wonder whether the lack of opportunity to prove heroic provides an adequate objective correlative for Colin's mood.To be sure, persistent sadness cannot be regarded as pathological if adequate reasons for sadness also persist. There lies the difference between mourning and melancholia. As Freud remarks at the outset of his comparison of the two, “although grief involves grave departures from the normal attitudes to life, it never occurs to us to regard it as a morbid condition and hand the mourner over to medical treatment.” Even though the mourner displays almost all the same symptoms as melancholia, where there is a recognizable objective correlative, we look upon any interference “as inadvisable or even harmful... because we know so well how to explain it... this attitude does not seem to us pathological” (Freud 1963, 165). Neither the absence of battlefield trauma nor the lack of heroic opportunities seems sufficient occasion for Colin's sadness. But (perhaps) that very explanatory insufficiency justifies regarding his plight as pathological, as a case of melancholia rather than mourning and therefore as warranting psychiatric interference. Insofar as that is true, the self-criticisms engendered by his trauma-free stint in Iraq might best be regarded as an effect rather than cause of his depression. Freud found this sort of “fall in self esteem” that “finds utterance in self reproaches and self revilings” to be the singular feature that distinguishes melancholia from mourning.” In the clinical picture of melancholia, dissatisfaction with the self on moral grounds is far the most outstanding feature” (Freud 1963, 167, 169).Anyone who has dealt with depression will recognize such feelings as standard symptoms. The DSM- IV cites “feelings of worthlessness or excessive or inappropriate guilt” as one of the defining criteria of a major depressive episode and “low self esteem” as a diagnostic criterion of dysthymic disorder.Freud speculated that the melancholic's attacks upon himself actually aim at an abandoned but internalized love object. But he acknowledged [End Page 245] that his speculation was based on “a small number of cases the psychogenic nature of which was indisputable,” and that some cases of melancholia suggest more somatic causes. Recent psychiatry has veered sharply toward somatic causes and cures, although the psychogenic nature of depression associated with traumatic stress is generally acknowledged. But in the absence of trauma and stress, as in Colin's case, a somatic account seems more plausible than supposing that the depression is triggered by that very absence.The contrast between somatic and psychological sources of depression threatens to prove distracting, however. We are not faced with a simple either/or here, and however we sort out the genetic, environmental, somatic, and psychological sources of depression in any given case, the depression itself is always a profoundly incarnate experience. Moreover, what seems of especial pertinence to this case, the loss of self-esteem and feelings of worthlessness and guilt seem to prevail regardless of the particular balance of causes of the depression and can, therefore, be regarded as characteristic symptoms rather than explanatory causes of the mood. And the blackness of melancholy typically extends well beyond such negative self-judgments to cast a shadow on the depressive's whole world and future.Epistemology and pathology converge in the clinical diagnosis of depression. Depression seems pathological insofar as it seems unreasonable in light of the circumstances as we apprehend them. Of course, the person who is depressed... (shrink)

First-person reports of Major Depressive Disorder reveal that when an individual becomes depressed a profound change or ‘shift’ to one’s conscious experience occurs. The depressed person reports that something fundamental to their experience has been disturbed or shifted; a change associated with the common but elusive claim that when depressed one finds oneself in a ‘different world’ detached from reality and other people. Existing attempts to utilise these phenomenological observations in a psychiatric context are challenged by the fact that (...) this experiential ‘shift’ characteristic of depression appears mysterious and resists analysis in scientific terms. This paper offers a way out of this predicament. The hypothesis proposed is that when an individual becomes depressed, the individual departs from a state of ordinary wakeful consciousness and enters a distinctive global state of consciousness akin to dreaming and the psychedelic state. After unpacking and motivating this hypothesis in the context of research in consciousness science, I outline two of its important implications for the neurobiology of depression and psychedelic psychiatry. The upshot is a promising and conceptually well-motivated hypothesis about depression which is apt for empirical uptake and development. (shrink)

Phenomenological psychiatry has suffered from a failure to translate its insights into terms specific enough to be applied to psychiatric diagnosis or to be used in contemporary research programs. This difficulty can be understood in light of the well-known tradeoff between reliability and validity. We argue, however, that with sufficient ingenuity, phenomenological concepts can be adapted and applied in a research context. Elsewhere, we have described a phenomenologically oriented conception of schizophrenia as a self- or ipseity-disorder with two (...) main facets: decline in the sense of existing as a subject of awareness (diminished self-affection) and heightened awareness of aspects of experience that would normally remain tacit or presupposed (hyperreflexivity). This approach is consistent with Minkowski, Blankenburg, and Kimura and offers one possible synthesis of their views. Here we describe two areas of empirical research that are congruent with, or actually inspired by, a phenomenological approach emphasizing such disorders of consciousness and self-experience: (1) Phenomenologically oriented, interview studies show that, whereas negative-symptom patients generally deny any diminishment of affect and thinking, they do describe qualitative alterations of experience suggestive of hyperreflexivity and diminished self-affection. (2) Another line of research suggests that the early detection of schizophrenic symptoms may be enhanced by adopting a phenomenological approach. (shrink)

Objective: The purpose of this study was to explore the rate of prolonged grief disorder and associated factors in a large sample of diverse college students. Sources of grief support and perceived helpfulness of support were also examined.Method: An online survey was administered to bereaved students at three colleges at the City University of New York. PGD measured by the Inventory of Complicated Grief was the primary outcome. Chi-squared and t-tests were used to assess the association between PGD and (...) associated factors.Results: A total of n = 899 participants completed the Inventory of Complicated Grief based on a significant death loss = >12 months. An estimated 13.4% met criteria for PGD. The rate of PGD was associated with race, history of anxiety or depression, trauma other than the death, insecure attachment style, kinship to the deceased, closeness to the deceased, cause of death, and sudden/unexpected death. The majority of students sought grief support from a friend or family member.Conclusion: The rate of PGD in this sample of college students is similar to that of adults and most prevalent for students of color. Identification of those most at risk is critical to referring these students to effective treatments. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Ambiguities of Mild Cognitive ImpairmentTim Thornton (bio)Keywordsclassification, disease, mild cognitive impairment, normative, valuesCorner and Bond's paper (2006) raises some key ethical questions about the classification and diagnosis of mild cognitive impairment (MCI). In this commentary, I wish to revise some of the general issues about the classification of mental disorder raised by this particular classificatory concept. The central issue raised is the connection between the pathologic status (...) of a condition and what I term the plain facts about the frequency and nature of its symptoms.There are a number of ethical questions raised by applying the label of MCI. Centrally, perhaps, is the concern, illustrated by the case vignettes, that a diagnosis carries negative repercussions that might outweigh the more narrowly medical advantages of an early diagnosis. But although that concern may be appropriate, such ethical complications are a danger of any psychiatric classification or diagnosis, even the most well grounded. Any psychiatric diagnosis can carry a danger of stigma, for example.What seems to make such ethical concerns more serious in this case—at least to a philosopher outsider—is the implicit further concern that MCI is not a real, objective, or, to use a more medical term, valid category or classification. If it is not valid, then any negative connotations of the diagnosis will not be outweighed by medical technological achievements. In other words, the further ethical issues are given much greater weight if the question of validity is not satisfactorily resolved.The question of the reality, objectivity, or validity of MCI can be divided into two issues:1. Is MCI a real, objective, or valid feature of psychological phenomenology?2. Is MCI a real, objective, or valid psychological illness, disease, or pathology?A condition might be a real, objective, or valid feature of psychological phenomenology without being a real illness. It might be some other aspect of human living. Szasz (1960) suggests that this is the case with mental illness (he might more properly say "so-called mental illness") as a whole. But, less controversially, the unusual ability to calculate, mentally and in a flash, the date of future Easter Sundays is a genuine feature of human living—some people possess the ability even if most do not—without either it, or its lack, being an illness. Being real as an illness is a very specific kind of being. It is this, I suggest, that raises difficulties in the case of MCI by contrast with the easier question of whether something is a genuine feature of human living in some other way. [End Page 21]From "normal" and "normative" to "correct" and "incorrect"Corner and Bond (2006) usefully suggest that the question of whether MCI is real is made more difficult by an ambiguity in the sense of the word normal. They suggest that although "physiologic and cognitive decline is assumed to be a normal experience" this still leaves "boundary problems" about "distinguishing normal aging from disease" (Corner and Bond 2006, 3–4). Thus, if the symptoms of MCI are continuous with the ordinary phenomena of physiologic and cognitive decline, then they might also be merely normal. But this does not settle the status of MCI because normal can mean either "normative, that is, usual; or it can mean nonpathologic" (Corner and Bond 2006, 4).On the assumption that MCI is at least continuous with phenomena that are normal, then its symptoms might be normal in the sense of usual but nevertheless pathologic: an inevitable illness. Or they might be usual and nonpathologic, that is, merely a feature of aging that, although regrettable, lacks the connotations of illness (e.g., the appropriateness, if not the possibility, of treatment). (In principle on the assumption in play—that the symptoms of MCI are normal—they might be unusual but nonpathologic akin, for example, to an improved ability to solve crosswords with age that might affect a small lucky proportion of the population. Perhaps such a crossword puzzler might be reassured by their doctor: "Well that is very unusual but there is no need to worry: it is not a symptom of any illness. You are perfectly normal.")Thus the question "Is MCI normal... (shrink)

The representation of illness manifestation during the first psychiatric interview with patients preliminary diagnosed with depressive illness The aim of the study is the analysis of patients' and doctors' discursive representation of mental health problems during the first psychiatric interview. The data comes from 16 initial psychiatric interviews recorded by doctors in three psychiatric hospitals in Poland. Assuming the discursive character of representation the analysis of the data has shown that the representation of illness manifestations in (...) doctors and patients narratives differs. The doctors constructed mental health problems mainly as static and timeless existence of medical symptoms and patients' traits. Conversely, the patients constructed illness manifestations in terms of action, as dynamic and contextualised processes. Interestingly, the patients deprived themselves of control over the acting illness manifestations. Doctors' static picture of illness manifestations eliminates the possibility of exploring the complicated relationship between patients and their problems. An examination of the way patients construct illness manifestations could be relevant diagnostic information. (shrink)

In this paper I offer an alternative phenomenological account of depression as consisting of a degradation of the degree to which one is situated in and attuned to the world. This account contrasts with recent accounts of depression offered by Matthew Ratcliffe and others. Ratcliffe develops an account in which depression is understood in terms of deep moods, or existential feelings, such as guilt or hopelessness. Such moods are capable of limiting the kinds of significance and meaning that one can (...) come across in the world. I argue that Ratcliffe’s account is unnecessarily constrained, making sense of the experience of depression by appealing only to changes in the mode of human existence. Drawing on Merleau-Ponty’s critique of traditional transcendental phenomenology, I show that many cases of severe psychiatric disorders are best understood as changes in the very structure of human existence, rather than changes in the mode of human existence. Working in this vein, I argue that we can make better sense of many first-person reports of the experience of depression by appealing to a loss or degradation of the degree to which one is situated in and attuned to the world, rather than attempting to make sense of depression as a particular mode of being situated and attuned. Finally, I argue that drawing distinctions between disorders of structure and mode will allow us to improve upon the currently heterogeneous categories of disorder offered in the DSM-5. (shrink)

Psychiatry has witnessed a new wave of approaches to clinical phenotyping and the study of psychopathology, including the National Institute of Mental Health’s Research Domain Criteria, clinical staging, network approaches, the Hierarchical Taxonomy of Psychopathology, and the general psychopathology factor, as well as a revival of interest in phenomenological psychopathology. The question naturally emerges as to what the relationship between these new approaches is – are they mutually exclusive, competing approaches, or can they be integrated in some way and used (...) to enrich each other? In this opinion piece, we propose a possible integration between clinical staging and phenomenological psychopathology. Domains identified in phenomenological psychopathology, such as selfhood, embodiment, affectivity, etc., can be overlaid on clinical stages in order to enrich and deepen the phenotypes captured in clinical staging (‘high resolution’ clinical phenotypes). This approach may be useful both ideographically and nomothetically, in that it could complement diagnosis, enrich clinical formulation, and inform treatment of individual patients, as well as help guide aetiological, prediction, and treatment research. The overlaying of phenomenological domains on clinical stages may require that these domains are reformulated in dimensional rather than categorial terms. This integrative project requires assessment tools, some of which are already available, that are sensitive and thorough enough to pick up on the range of relevant psychopathology. The proposed approach offers opportunities for mutual enrichment: clinical staging may be enriched by introducing greater depth to phenotypes; phenomenological psychopathology may be enriched by introducing stages of severity and disorder progression to phenomenological analysis. (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)

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)

In this review essay, the author commends Matthew Ratcliffe for his masterful and highly valuable account of the emotional phenomenology of existential change—of shifts in our experience of belonging to a shared world of possibilities—but criticizes him for his commitments to two frameworks that are actually extraneous and inimical to his project and that perpetuate remnants of Cartesian isolated-mind thinking—Husserlian ‘‘pure phenomenology’’ and traditional diagnostic psychiatry. The author contends that Ratcliffe’s devotion to a decontextualizing psychiatric language in particular conceals (...) the contexts of severe emotional trauma in which the existential feelings that he so beautifully elucidates take form. (shrink)

In Real Hallucinations, Matthew Ratcliffe offers a philosophical examination of the structure of human experience, its vulnerability to disruption, and how it is shaped by relations with other people. He focuses on the seemingly simple question of how we manage to distinguish among our experiences of perceiving, remembering, imagining, and thinking. To answer this question, he first develops a detailed analysis of auditory verbal hallucinations (usually defined as hearing a voice in the absence of a speaker) and thought insertion (somehow (...) experiencing one's own thoughts as someone else's). He shows how thought insertion and many of those experiences labeled as "hallucinations" consist of disturbances in a person's senseof being in one type of intentional state rather than another. Ratcliffe goes on to argue that such experiences occur against a backdrop of less pronounced but wider-ranging alterations in the structure of intentionality. In so doing, he considers forms of experience associated with trauma, schizophrenia, and profound grief. The overall position arrived at is that experience has an essentially temporal structure, involving patterns of anticipation and fulfillment that are specific to types of intentional states and serve to distinguish them phenomenologically. Disturbances of this structure can lead to various kinds of anomalous experience. Importantly, anticipation-fulfillment patterns are sustained, regulated, and disrupted by interpersonal experience and interaction. It follows that the integrity of human experience, including the most basic sense of self, is inseparable from how we relate to other people and to the social world as a whole. (shrink)

This volume addresses the question of what it is like to be depressed. Despite the vast amount of research that has been conducted into the causes and treatment of depression, the experience of depression remains poorly understood. Indeed, many depression memoirs state that the experience is impossible for others to understand. However, it is at least clear that changes in emotion, mood, and bodily feeling are central to all forms of depression, and these are the book's principal focus. In recent (...) years, there has been a great deal of valuable philosophical and interdisciplinary research on the emotions, complemented by new developments in philosophy of psychiatry and scientifically-informed phenomenology. The book draws on all these areas, in order to offer a range of novel insights into the nature of depression experiences. To do so, it brings together a distinguished group of philosophers, psychiatrists, anthropologists, clinical psychologists and neuroscientists, all of whom have made important contributions to current research on emotion and/or psychiatric illness. (shrink)

ABSTRACTAnxiety and depression diagnoses are associated with suicidal thoughts and behaviours. However, a categorical understanding of these associations limits insight into identifying dimensional mechanisms of suicide risk. This study investigated anxious and depressive features through a lens of suicide risk, independent of diagnosis. Latent class analysis of 97 depression, anxiety, and suicidality-related items among 616 psychiatric outpatients indicated a 3-class solution, specifically: a higher suicide-risk class uniquely differentiated from both other classes by high reported levels of depression and (...) anxious arousal; a lower suicide-risk class that reported levels of anxiety sensitivity and generalised worry comparable to Class 1, but lower levels of depression and anxious arousal; and a low to non-suicidal class that reported relatively low levels across all depression and anxiety measures. Discriminants of the higher suicide-risk class included borderline personality disorder; report... (shrink)

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 lieu of an abstract, here is a brief excerpt of the content:Psychiatric Comorbidity:More Than a Kuhnian AnomalyPeter Zachar (bio)Keywordscomorbidity, classification, epidemiology, differential diagnosis, personality disorderDr. Aragona's article in this issue of Philosophy, Psychiatry, & Psychology makes some important points regarding the relationship between comorbidity rates and the classification system currently used in psychiatry. Particularly persuasive is his claim that observed patterns of comorbidity are, in important respects, consequences of the structure of the classification system. I am not (...) convinced, however, that comorbidity is best conceptualized as an artifact of the taxonic structure of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD). Instead, I suggest that the use of dichotomies such as true versus artifactual should be used with caution when psychiatric classification is being discussed.In contrast with the artifact hypothesis, I argue that the phenomena covered by the term "comorbidity" are real, expectable features of the psychiatric domain. They are not the phlogiston and luminiferous ether of psychiatry. I am skeptical of the notion that high comorbidity rates as a whole can be understood as Kuhnian anomalies, or that there is a crisis, or that after a period of revolutionary science a new paradigm would eliminate these 'anomalies.' In short, high rates of comorbidity in psychiatry will not simply disappear once scientists develop a better nosological paradigm. High levels of comorbidity can, however, be both lowered and provided a better, evidence-based conceptual framework.Many Conditions, One OrganIn general medicine, comorbidity conventionally refers to the simultaneous occurrence of two independent disease processes or distinct clinical entities, such as heart disease and liver cancer (Feinstein, 1970; Jablensky 2004). The presence of one disease is supposed to affect the other in such a way that the co-occurrence of the two has implications for prognosis and treatment.Comorbidity in psychiatry is a broader concept, referring to a variety of conditions that overlap in multiple ways. The different kinds of overlap are amenable to detailed empirical analysis (e. g., Klein and Riso 1993; Neale and Kendler 1995). Depressive reactions to primary disorders, attention deficit symptoms associated with mania, panic attacks in the context of severe borderline personality disorder, substance abuse disorders among psychopaths, histrionic dynamics combined [End Page 13] with narcissistic personality traits, and emergent conditions such as schizoaffective disorder are all distinct types of comorbidity. The kinds of overlapping conditions just listed are sometimes termed psychiatric comorbidity. Also important is comorbidity between psychiatric disorders and general medical conditions as is studied in behavioral medicine and health psychology. The crisis, if there is one, is a crisis of comorbidities.The heart disease and liver cancer type of comorbidity as independent organ systems being affected is ruled out a priori in psychiatric comorbidity proper. In psychiatry, "psychopathological disease processes" can all be expected to affect a single organ, namely the brain or, more likely, affect the different systems that are tightly integrated in the brain. The tight integration can make putative comorbid psychiatric disorders difficult to disentangle.It is a widely held consensus that causes, not organ systems, are what matter in comorbidity. In this tradition, Dr. Aragona claims that in general medicine shared symptoms between two diseases (such as fever and fatigue) are not a problem because the diseases are differentiated with respect to etiology; in psychiatry, however, where syndromes are differentiated by a description of symptoms only, symptomatic overlap is a problem.Is descriptive psychopathology, therefore, a root cause of the "crisis of comorbidity" and should it be abandoned in favor of etiological classification? Unfortunately, forcing psychiatric nosology to conform to an etiological paradigm is unlikely to resolve the problem of psychiatric comorbidity. As noted, the problem is one of distinguishing between the different etiological disease processes that are affecting tightly integrated systems in the brain. The brain as a whole is a multilevel, dynamic, and open system, which has an ecology (Zachar 2000). As argued by Kendler (2005) and Schaffner (2002, 2008), it has not thus far, and may never be fully possible to segregate causes and their associated psychiatric disorders into parsimonious etiological packages. In the ecology of neuroscience, causes and effects tend to merge in a continuous series of common pathways.It would be foolish... (shrink)

This dissertation is a contribution to the contemporary field of phenomenological psychopathology, or the phenomenological study of psychiatric disorders. The work proceeds with two major aims. The first is to show how a phenomenological approach can clarify and illuminate the nature of psychopathology—specifically those conditions typically labeled as major depressive disorder and bipolar disorder. The second is to show how engaging with psychopathological conditions can challenge and undermine many phenomenological presuppositions, especially phenomenology’s status as a transcendental philosophy and its (...) corresponding anti-naturalistic outlook. In the opening chapter, I articulate the three layers of the subject matter of phenomenological research—what I refer to as “existentials,” “modes,” and “prejudices.” As I argue, while each layer contributes to what we might call the “structure” of human existence, they do not do so in the same way, or to the same degree. Because phenomenological psychopathology—and applied phenomenology in general—aims to characterize how the structure of human existence can change and alter, it is paramount that these layers be adequately delineated and defined before investigating these changes. In chapters two through five, I conduct hermeneutic and phenomenological investigations of psychopathological phenomena typically labeled as major depressive disorder or bipolar disorder. These investigations address the affective aspects of depression and mania, and the embodied aspects of depression. In addition to clearly articulating the nature of these phenomena, I show how certain psychopathological conditions involve changes in the deepest or most fundamental layer of human existence—what I refer to as existentials. As I argue, many of the classical phenomenologists (including Husserl and Heidegger) believed that these structural features were necessary, unchanging, and universal. However, this presupposition is challenged through the examination of psychopathological and neuropathological conditions, undermining the status of phenomenology as a transcendental philosophy. While this challenge to classical phenomenology is only sketched in the early chapters, in chapters six and seven I develop it in more detail in order to achieve two distinct ends. In chapter six I argue that psychopathology and neuropathology not only challenge phenomenology’s status as a transcendental philosophy, but also supply a key to developing a phenomenological naturalism (which I contrast with a naturalized phenomenology). Phenomenological naturalism, as I articulate it, is a position in which phenomenology is not subsumed by the metaphysical and methodological framework of the natural sciences, but nonetheless maintains the capacity to investigate how the natural world stands independent of human subjectivity (and how events in the natural world can bring about changes in the most fundamental structures of human existence). In the seventh chapter I argue that a phenomenology in which existentials are contingent and variable rather than necessary and unchanging allows phenomenologists to contribute to new dimensional approaches to psychiatric classification. Rather than begin from distinct categories of disorder, these approaches begin from distinct core features of human existence. These features, referred to as either dimensions or constructs, can vary in degree and are studied in both normal and pathological forms. (shrink)

Ginger Hoffman and Jennifer Hansen’s study of gender dynamics in psychiatric disability memoirs makes several fruitful moves for the study of psychic diversity. Perhaps the most important is that the article encourages analytic philosophers to contribute to understanding how individual mental life is affected by the larger cultural context—which we can think of as the “mind/culture” problem. This is an important move because, for the most part, analytic philosophers have paid more attention to the mind/body problem than they have (...) to the mind/culture problem. Hoffman and Hansen are right that it would be valuable for analytic philosophy to join in the study of this equally complicated conceptual problem.... (shrink)

This paper explores similarities and differences between grief over the death of a person and other experiences of loss that are sometimes termed 'grief', focusing on the impact of serious illness and bodily injury. It takes the form of a dialogue between a physician/ neurophysiologist and a philosopher. Adopting a broad conception of grief, we suggest that experiences of lost or unrealized possibilities are central to all forms of grief. However, these unfold in different ways over prolonged periods. Experiences of (...) grief are complex, diverse, difficult to articulate, and frequently under-acknowledged. This diversity, we note, complicates discussions of how to distinguish typical from pathological forms of grief. We raise the concern that thinking of grief through the lens of bereavement eclipses other circumstances in which people are required to comprehend and adapt to loss. With this lack of acknowledgment, the phenomenology of grief is characterized in ways that are overly tidy and people are deprived of important interpretive resources. (shrink)

Central and peripheral biomarkers can be used to diagnose, treat, and potentially prevent major psychiatric disorders. But there is uncertainty about the role of these biological signatures in neural pathophysiology, and their clinical significance has yet to be firmly established. Psychomotor, cognitive, affective, and volitional impairment in these disorders results from the interaction between neural, immune, endocrine, and enteric systems, which in turn are influenced by a person’s interaction with the environment. Biomarkers may be a critical component of this (...) process. The identification and interpretation of biomarkers also raise ethical and social questions. This article analyzes and discusses these aspects of biomarkers and how advances in biomarker research could contribute to personalized psychiatry that could prevent or mitigate the effects of these disorders. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Anthropological Perspectives in Psychiatric NosologyJuan J. López-Ibor Jr. (bio) and María-Inés López-Ibor (bio)KeywordsDSM, etiology, Aristotelian causes, social dramasPsychiatry and clinical psychology, as we learn in this paper, are disciplines in need of an ontological perspective. Very few branches of contemporary learning share this characteristic. Probably only theoretical physic and theology—as the rest have long ago given up trying to define and understand the essence of their object, for (...) example, life in the case of biology or mind in psychology. Consequently, the paper by Pérez-Álvarez, Sass and García-Montes, “The Ontology of Mental Disorders in Constructivist Perspective,” (2008) should be welcomed and indeed included in the reading lists for trainees in psychiatry and clinical psychology.The authors propose an approach to the understanding of mental disorders that is extremely attractive and well articulated, and which also has practical implications for clinicians. It is not just another “philosophical divertimento” devoid of scientific and practical importance. Let us analyze the article in an orderly way.Less DsmThe authors of the target paper disapprove of the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III/IV approach to defining illnesses by starting from the symptoms that are present—on the grounds that this may lead clinicians to assume that their sole role is to identify, fight, and suppress the symptoms by whichever procedure. They propose an alternative that is dear to myself because it follows the path of the so-called “anthropological” psychiatry of Binswanger, von Gebsattel, Erwin Strauss, Zutt, López-Ibor, Sr., and others. In essence, this is a phenomenological approach to the meaning of mental diseases, one that emphasizes how the illness is revealed to the patient him- or herself.The target article’s criticism of DSM should be considered in the context of the abuses committed on its behalf. The DSM is not a textbook of psychiatric disorders, nor does it contain a definition of the diseases. The DSM does not tell what a disease is (Klerman et al. 1984)—something that is impossible with a classification system based on the manifestations of the diseases, the signs and symptoms. The DSM, as its title states, is just a diagnostic and statistical manual, which does not contain anything about the origin of [End Page 259] any disease nor an explanation of why it exists or what it means. The DSM is, in fact, just a tool to determine whether a disease is present, and therefore to facilitate communication between professionals and with other individuals, without saying anything about the disease’s aitia—a key term (associated with notions of essence as well as cause) to be discussed below. In theory, most clinicians should understand these limitations; it may be, however, that this is not really the case for many who read or use the DSM. In the world there are around 200,000 psychiatrists; since 1980 the number of DSM copies sold is in the order of several hundred thousand.The misuse of a classification system is even more noticeable in the International Classification of Diseases (ICD)-10 Research Version. The instructions for the use of this version recommend that the first step is to make an inventory of all the symptoms present, and then to construct a diagnosis based on them. This how all computer-assisted systems work. This procedure can, however, only be valid if the clinician has already reached a diagnostic conclusion by other means—a diagnosis then to be confirmed for research purposes. It may be that this is one of the reasons why the ICD-10 Research Version has almost never actually been used for research.Furthermore, the concept of symptoms in psychiatry applies only to organic mental disorders (Schneider 1959), conditions in which the patient’s attitude and way of experiencing the symptoms do not play the kind of role that they play in schizophrenia and other mental disorders. The quotation from the important paper by Sass and Parnas in this context is most appropriate. It is indeed that case that “subjective experience can play an important causal role in the progressive experiential transformations of a developing schizophrenic illness... (shrink)

Writing is central both to the medical diagnostic codification of disability and to disabled people’s efforts to interrupt, complicate, or disrupt dominant medical narratives. This Symposium, like the George Washington University conference from which it takes its name, creates space for diverse modes and genres of claiming authority regarding diagnosis and its cultural and material effects. “Queer” and “crip” interrogations of diagnosis illuminate its status as a cultural phenomenon, embracing culturally disavowed embodiments and embodied experiences as tools for (...) diagnosing inegalitarian social relations and opportunities for cultural interventions. This Symposium traces the workings of diagnostic normativity manifested in experiences such as “disruptive deafness,” unstable bodily materialities, pathologized grief and other forms of affective distress, and “surgical assemblages.” It presents a diverse array of compositions, articulated on each writer’s own terms, addressing a range of embodied experiences through multiple genres and voices, ranging from conversation transcript to scholarly essay, poetry, graphic memoir, and personal essay. Here, laypersons interrupt monologic medical diagnosis, claiming space to compose themselves. Together, the authors trace instances of corporeal “correction” back to the noxious agents, both environmental and political, that consistently breach the boundaries of corporeality. (shrink)

Working toward a phenomenological account of depression, this article suggests that the relevant level of analysis is that of experiential immediacy based on intersubjectivity. The argument focuses on the experience of one boy and one girl who participated in the study Southwest Youth and the Experience of Psychiatric Treatment (SWYEPT), in which we followed the experience of adolescent psychiatric inpatients and their families over the course of a year. I emphasize the role of language as a form of (...) disclosure and empathy in the interview setting in elaborating a set of criteria for inferring immediacy from interview data, and point to how illness experience is bound up with domains of the life-world such as relationships, religion, morality, reflexivity, identity, and treatment. (shrink)

Psychiatrists' accounts of clinical significance in depression Clinical significance is a crucial element in the diagnosis of mental illness, yet, it is practically untheorised and significantly under-researched. This article takes up the question of how the criterion of clinical significance is translated into psychiatric practice. More particularly, it examines how psychiatrists account for the threshold between health and depression. The paper is anchored in the constructionist view of discourse underpinned by the assumptions of critically oriented discourse analysis. It (...) is based upon a convenience sample of 39 semi-structured interviews with specialist-psychiatrists in south-western Poland. There is no discursive space for clinical significance in psychiatrists' accounts. There is no boundary, no decision to be taken as to whether the symptoms are clinically significant. Depression, invariably constructed in terms of diagnostic criteria, is always represented as fully developed, appearing out of thin air, with no period of falling ill. The article raises the issue of the validity and usefulness of psychiatric diagnosis. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 9.1 (2002) 87-90 [Access article in PDF] Phenomenological and Biological Psychiatry:Complementary or Mutual? James Morley Keywords: phenomenology, psychiatry, psychoanalysis, ontology. We feel that even if all possible scientific questions be answered the problems of life have still not been touched at all. (Witgenstein, Tractatus, 6.52) IF ONE WAS TO PERFORM a thought experiment by imagining a scientifically explained universe, how would this explained universe resolve (...) my issues of value and meaning? Would it help me to live a better life? In one sentence, Witgenstein expressed exactly the issues dividing, and defining, the phenomenological and biophysical approaches to psychiatry. (Natural) scientific questions are concerned with relations of physical causality while phenomenology is aimed at the problems of life, i.e., the elucidation of lived personal meanings.Clarifying the relation between phenomenology and the general psychiatric literature is clearly a significant undertaking. At this juncture in the history of psychiatry where the biophysical model is so dominant, the authors' efforts are especially welcome, as I wholeheartedly appreciate, and thank the authors for this endeavor. I only wish to explicate a few issues latent within the article and perhaps add a few supportive points. Explicitly or implicitly, the need for phenomenology in psychiatry is long enduring and will always persist (Ellenberger 1981, 1993). The integration of phenomenology with general psychiatric practice would certainly serve the needs of patients and society generally. But, in the present state of affairs where the biological model is so preeminent, a full accounting of the dramatic divergences between the two approaches is necessary if there is to be authentic dialogue between them.Essentially, I want to stress that phenomenology and natural science medicine are genuinely distinct paradigms for construing reality and organizing knowledge. As distinct scientific paradigms, each one is holistically self-contained. Like soap bubbles, if pushed together too forcefully one or the other may burst. In this case, it is more likely that the smaller, less prevalent paradigm would burst by becoming absorbed into the more dominant paradigm. I believe that this is precisely the risk when phenomenology is introduced to conventional psychiatry as "complementary." Whereas one could hardly object to any application of empathy and understanding toward the experiences of patients, it would be tragic if the [End Page 87] full philosophical power of phenomenology were to be overlooked in favor of its mere utility as a preliminary stage of diagnosis and assessment, a framework for bedside manners, or worst of all, an appendage to neuroscience or pharmacology. This would not be phenomenology but the very symptomatology that the authors have has so clearly distinguished from true phenomenology.This equation of phenomenology with symptomatology is exactly the misunderstanding that the authors so effectively address. However, I would hesitate to join the authors' optimism in regard to phenomenology's potential complementary role to conventional psychiatric practice. Furthermore, in the process of paradigm mix, certain constituents of each paradigm may be taken out of context and the strength of each paradigm thus diluted. For example, the very power of the experimental method is its reduction of phenomena to measurable variables that can be altered in order to discern causality. Unmeasurable variables detract form the rigor of this entire approach. Then on the other hand, phenomenological empathy is only possible within a standpoint that is severed from the causal thinking of experimental science. This is the holistic perceptual shift that cannot be accomplished when one only appends phenomenological insights to an otherwise materialist approach to psychiatry. Thus, it is not at all clear how one can be both phenomenological and nonphenomenologically natural scientific. Instead of positioning phenomenology as a potential complimentary component of natural-science psychiatry, both world views need to be examined, on their own terms, in a framework of mutuality.Empathy or the understanding of other peoples subjective experience is indeed an essential component of the application of phenomenology to clinical assessment and especially therapeutic treatment. But, to limit phenomenology to this theme alone may not honor the profoundly radical character of this paradigm. As the authors point out, phenomenology asks the practitioner to... (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 diagnoses are increasingly seen as viable categories around which self and social identities might be drawn. This introduces a new pressure on the “boundary problem” for psychiatry: when members of the public request diagnoses to affirm their self-identities how should we draw the line between mental disorder and normality? If psychiatrists have the authority to recognize and diagnose mental disorder, how can roles as diagnosers and gate-keepers be balanced in a post-stigma era of mental health care? Focusing on (...) the disorder identified would-be patient who would not attract the diagnosis they seek were they not to seek it, this essay explores what it means to have an identity bound to a psychiatric diagnosis and considers a framework for psychiatrists to negotiate clinical encounters that involve the seeking of identity affirming diagnoses. (shrink)

Objectives: To examine the experiences of spousal care givers of Alzheimer patients to disclosure of dementia diagnosis and subsequent care.Methods: A random sample of 1943 spousal care givers of people receiving medication for Alzheimer disease was sent a cross-sectional postal survey about their opinions on the disclosure of dementia and follow-up care. A smaller qualitative study included open-ended questions concerning their experiences of the same topics.Results: The response rate for the survey was 77%. Of the respondents, 1214 of 1434 (...) acknowledged themselves as their spouse’s care giver. The mean age of the care givers was 78.2 years, and that of demented spouses, 80.5 years. Of the care givers, 63% were women. The couples had long-lasting marriages. Of the care givers, 93% reported that dementia had been disclosed openly to their spouse; 97% also preferred that physicians openly inform the patients of the dementia diagnosis, although 55% of their spouses with AD had developed depressive symptoms after the disclosure. Of the care givers, 71% felt they had received sufficient information about dementia. However, only 50% estimated that their spouses’ follow-up care had been well organised. The responses in the qualitative study indicated that many care givers felt grief and anxiety. They also expressed feelings of loneliness and uncertainty about how to deal with follow-up care for dementia.Conclusions: Elderly spousal care givers were quite satisfied with the information given them about dementia. However, the support with regard to the follow-up care of care-giving families failed to meet their needs adequately. (shrink)